3220-0034

OMB NO. 3220-0034

Justification

Statement of Authority to Act for Employee

RRB Form SI-10

1. Circumstances of information collection - Under Section 5(a) of the Railroad Unemployment Insurance Act (RUIA) (45 U.S.C. 355), claims for benefits under that Act are to be made in accordance with such regulations as the Railroad Retirement Board (RRB) shall prescribe. The provisions for claiming sickness benefits as provided by Section 2 of the RUIA are prescribed in 20 CFR 335.2. Included in these provisions is the RRB's acceptance of someone signing forms on behalf of the employee, if the RRB is satisfied that the employee is sick or injured to the extent of being unable to sign.

20 CFR 348, Representative Payment under the Railroad Unemployment Insurance Act, addresses situations where there is evidence of guardianship or incompetence, and the RRB determines that the appointment of a representative payee for the beneficiary is necessary. Form SI-10, Statement of Authority to Act for Employee, is not prescribed for use in the process of appointing a representative payee. Instead, Form SI-10 is used when the beneficiary, though competent to handle his or her own affairs, is sick or injured to the extent of being unable to sign forms.

2. Purpose of collecting/consequences of not collecting the information - Form SI-10, Statement of Authority to Act for Employee, has two purposes; to provide the means for an individual to apply for authority to act on behalf of an incapacitated employee and to provide the means for the RRB to obtain the information necessary to satisfy itself that the delegation should be made. Form SI‑10 is provided both as a stand-alone form with a cover page that contains the Paperwork Reduction Act and Privacy Act Notices and as part of Forms SI-1a, Application for Sickness Benefits, and SI-1b, Statement of Sickness (3220-0039), included in the booklet UB‑11, Sickness Benefits for Railroad Employees. The Paperwork Reduction Act and Privacy Act Notices that cover the SI-10 are included in the UB‑11 booklet.

Section 1 of the SI‑10 is completed by the applicant for the authority and Section 2 is completed by the employee's doctor. Completion of the form is self-explanatory.

When possible, the form is preprinted by the initiating RRB office with the name, social security number, and address of the incapacitated employee. After Sections 1 and 2 are completed by the applicant and the employee's doctor, respectively, the form is returned by the applicant to the initiating RRB office in a self-return envelope provided by the RRB, or to the RRB headquarters in Chicago.

The RRB proposes no changes to Form SI-10.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction - Not cost effective due to low volume.

4. Efforts to identify duplication - To our knowledge, no other agency uses a form similar to Form SI-10.

5. Small business respondents - N.A.

6 Consequences of less frequent collection - Not applicable since the information is obtained only once.

7. Special circumstances - N.A.

8. Public comments/consultations outside the agency - In accordance with 5 CFR 1320.8(d), comments were invited from the public regarding this information collection. The notice to the public was published on page 62777 of the October 5, 2020, Federal Register. No comments or requests for additional information were received.

9. Payments or gifts to respondents - None

10. Confidentiality - Privacy Act System of Records, RRB-21, Railroad Unemployment and Sickness Insurance Benefit System - In accordance with OMB Circular M-03-22, a Privacy Impact Assessment for this information collection was completed and can be found at https://www.rrb.gov/sites/default/files/2017-06/PIA-BPO.pdf.

11. Sensitive questions - N.A.

12. Estimate of respondent burden - The estimated burden for this collection is changed as follows:

Current Burden

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
SI-10	32	6	3

Proposed Burden

Form Number	Annual Responses	Time (Minutes)1/	Burden (Hours)
SI-10	30	6	3

1/The RRB has been collecting the information on these forms since OMB approved the information collection. Based on a sampling done when the form was originally created, the office calculated the estimated time, which includes time for getting the needed data and reviewing the completed form.

Responses Hours

Total burden change -2 0

Adjustment -2 0

13. Estimated annual cost to respondents or record keepers - N.A.

14. Estimate of cost to Federal Government - N.A.

15. Explanation for change in burden – Based on our most recent three-year record of responses received, the estimated annual responses have decreased from 32 to 30 and no change to the burden hours. This decrease more accurately reflects the number of sickness claimants that are unable to act on their own behalf. We have shown the decrease as an adjustment.

16. Time schedule for data collections and publications - The results of this collection will not be published.

17. Request not to display OMB expiration date - The RRB started an extensive multi-year IT Modernization Initiative at the beginning of Fiscal Year 2019 to transform our operations into the 21^st Century using multiple contractor services to improve mission performance, expand service capabilities, and strengthen cybersecurity. In addition, we received a new Chief Information Officer (CIO) on September 2, 2019 who is reviewing our estimated project timeline milestone dates. We provided OMB with a consolidated project timeline.

Given that the forms in this collection are seldom revised; the costs associated with redrafting, reprinting, and distributing forms in order to keep the appropriate OMB expiration date in place; and our desire to reevaluate after the completion of the modernization project, the RRB requests the authority to not display the expiration date on the forms.

18. Exceptions to Certification Statement - None.