Information Collection

Railroad Unemployment Insurance Act Applications

IC 179107 under ICR 202007-3220-001 · OMB 3220-0039.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 3220-0039 can be found here:

2025-01-10 - Reinstatement without change of a previously approved collection
2023-08-02 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SI-1b (06-09) Statement of Sickness Railroad Unemployment Insurance Act Applications	Form and Instruction
Form SI-7 (03-17) Supplemental Doctor's Statement Railroad Unemployment Insurance Act Applications	Form and Instruction
Form SI-8 (02-17) Railroad Unemployment Insurance Act Applications	Form and Instruction
Form SI-8 (02-17) Verification of Medical Information Railroad Unemployment Insurance Act Applications	Form and Instruction
Form SI-1b (xx-xx) Statement of Sickness Railroad Unemployment Insurance Act Applications	Form and Instruction
SI-1b (06-09) Statement of Sickness Form SI-1b (06-09).pdf	Form and Instruction
SI-1b (06-09) Statement of Sickness Form SI-1b (06-09).pdf	Form and Instruction
SI-7 (03-17) Supplemental Doctor's Statement Form SI-7 (03-17).pdf	Form and Instruction
SI-7 (03-17) Supplemental Doctor's Statement Form SI-7 (03-17).pdf	Form and Instruction
SI-8 (02-17) Verification of Medical Information Form SI-8 (02-17).pdf	Form and Instruction
SI-8 (02-17) Verification of Medical Information Form SI-8 (02-17).pdf	Form and Instruction
SI-1b (xx-xx) Statement of Sickness Form SI-1b (xx-xx) - Proposed.pdf	Form and Instruction
SI-1b (xx-xx) Statement of Sickness Form SI-1b (xx-xx) - Proposed.pdf	Form and Instruction
UB-11 (03-12).pdf UB-11, Sickness Benefits for Railroad Employees	IC Document
UB-11 (03-12).pdf UB-11, Sickness Benefits for Railroad Employees	IC Document
Form SI-10 (05-17) stand alone.pdf SI-10, Statement of Authority to ACt for Employee	IC Document
Form SI-10 (05-17) stand alone.pdf SI-10, Statement of Authority to ACt for Employee	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Railroad Unemployment Insurance Act Applications

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 355

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SI-1b (06-09)	http:www.rrb.gov/pdf/PandS/ub11.pdf	Yes	No	Printable Only
Form and Instruction	SI-7 (03-17)		No		Paper Only
Form and Instruction	SI-8 (02-17)		No		Paper Only
Form and Instruction	SI-1b (xx-xx)	http:www.rrb.gov/pdf/PandS/ub11.pdf	Yes	No	Printable Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Income Security

Subfunction: Unemployment Compensation

Privacy Act System of Records

Title: RRB-21, Railroad Unemployment and Sickness Insurance Benefit System

FR Citation: 79 FR 58874

Number of Respondents: 36,556

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	36,556	36,556
Annual IC Time Burden (Hours)	4,872	4,872
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
UB-11, Sickness Benefits for Railroad Employees		03/27/2014
SI-10, Statement of Authority to ACt for Employee		08/20/2020

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].