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⚠️ Notice: This information collection may be referencing outdated material.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:

Documents and Forms

Document Name Document Type
Form SI-8 (02-17) Railroad Unemployment Insurance Act Applications Form and Instruction
SI-1b (06-09) Statement of Sickness Form SI-1b (06-09).pdf http:www.rrb.gov/pdf/PandS/ub11.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-1b (xx-xx) Statement of Sickness Form SI-1b (xx-xx) - Proposed.pdf http:www.rrb.gov/pdf/PandS/ub11.pdf Form and Instruction
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

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	SI-1b (06-09)	Statement of Sickness	Form SI-1b (06-09).pdf	http:www.rrb.gov/pdf/PandS/ub11.pdf	Yes	No	Printable Only
Form and Instruction	SI-7 (03-17)	Supplemental Doctor's Statement	Form SI-7 (03-17).pdf		No		Paper Only
Form and Instruction	SI-8 (02-17)	Verification of Medical Information	Form SI-8 (02-17).pdf		No		Paper Only
Form and Instruction	SI-1b (xx-xx)	Statement of Sickness	Form SI-1b (xx-xx) - Proposed.pdf	http:www.rrb.gov/pdf/PandS/ub11.pdf	Yes	No	Printable Only

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 %

	Requested	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

Title	Document	Date Uploaded
UB-11, Sickness Benefits for Railroad Employees	UB-11 (03-12).pdf	03/27/2014
SI-10, Statement of Authority to ACt for Employee	Form SI-10 (05-17) stand alone.pdf	08/20/2020

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