3220-0039

OMB No. 3220-0039

Justification

Railroad Unemployment Insurance Act Applications

RRB Forms SI-1a, SI-1b, SI-3, SI-3 (Internet),

SI-7, SI-8, and ID-11A

1. Circumstances of information collection - Under Section 2 of the Railroad Unemployment Insurance Act (RUIA) (45 U.S.C. 362), sickness benefits are payable to qualified railroad employees who are unable to work because of illness or injury. In addition, sickness benefits are payable to qualified female employees if they are unable to work, or if working would be injurious, because of pregnancy, miscarriage, or childbirth. Under Section 1(k) of the RUIA, a statement of sickness, with respect to days of sickness of an employee, is to be filed with the Railroad Retirement Board (RRB) within a 10-day period from the first day claimed as a day of sickness. The RRB's authority for requesting supplemental medical information is Section 12(i) and 12(n) of the RUIA.

The procedures for claiming sickness benefits and for the RRB to obtain supplemental medical information needed to determine a claimant's eligibility for such benefits are prescribed in 20 CFR Part 335.

2. Purpose of collecting the information - The forms currently used by the RRB to obtain the information needed to determine eligibility for, and the amount of, sickness benefits due a claimant follow.

Forms SI-1a, Application for Sickness Benefits and SI-1b, Statement of Sickness, are submitted to the RRB when a railroad employee wishes to claim sickness benefits. Form SI‑1a acts as an application and the first claim. To satisfy a 1-week waiting period requirement, no benefits are payable to an employee for his or her first 7 days of sickness in the first claim period of continuing sickness unless they have already satisfied the waiting period requirement in the benefit year. However, if the employee has at least 5 days of sickness in the 14-day registration period, he or she should file a Form SI-1a and have an SI‑1b completed by his or her doctor. Even though no benefits would be payable, the filing of the SI-1a, along with the medical evidence provided on the SI-1b serves, in most cases, as the employee's first claim in the benefit year. Future benefits may then be claimed and received by the employee in subsequent registration periods for any sick days more than four in each registration period during the remaining benefit year.

Form SI-1a, which is completed by the employee or by someone else on the employee's behalf, requests identifying information, data about the employee's last employer, accident and insurance information, other benefits received for days of sickness, and direct deposit information. Form SI-1b is completed by the railroad employee's doctor to support the employee's claim of the inability to work because of illness or injury. As a convenience, on the reverse side of Form SI-1b is Form SI-10, Statement of Authority to Act for Employee (OMB No. 3220-0034), which enables a spouse or other person to complete and sign RRB sickness benefit forms on behalf of the employee who is incapable of signing forms. Only a small percentage of applicants will need to have Form SI-10 completed.

The RRB proposes no changes to Form SI-1a.

The RRB proposes minor non-burden impacting changes to the form SI-1b:

• update the officer title and

• update RRB zip code in the Paperwork Reduction Act/Privacy Act Notices section.

Form SI-3, Claim for Sickness Benefits, which is used to claim additional sickness benefits, is sent by the RRB to a claimant who has previously filed for sickness benefits on Forms SI‑1a/1b. The form notifies the claimant of the registration period covered by the claim (normally 14 days) and instructs the claimant to furnish information regarding days of sickness, days worked, and other benefits. In addition, space is provided for the claimant to report receipt of various payments that affect benefit eligibility. The form is used by a claimant for sickness benefits due to pregnancy just as in any other sickness benefit cases.

When the claimant returns a completed Form SI-3, the RRB sends another Form SI-3 for the next 14-day period, and so on, until (1) the probable ending date of inability to work is reached, (2) the claimant reports returning to work, or (3) sickness benefits are exhausted, whichever occurs first.

In circumstances where the probable ending date of inability to work is reached first, the claimant is advised that no further sickness benefits will be paid unless additional medical evidence is submitted.

The RRB proposes no changes to Form SI-3.

Form SI-3 (Internet), Claim for Sickness Benefits, provides railroad employees with an Internet filing option as part of the RRB’s overall plan to provide its customers with the option to submit information or to transact business electronically, when practical, as a substitute for paper.

Before Form SI-3 (Internet) can be filed electronically, a claimant must apply for a Password Request Code (PRC) from the RRB. After receiving the PRC the claimant must establish a PIN/Password (OMB approved 3220-0198) online to gain access to the sickness application and claim forms.

Form SI-3 (Internet) essentially collects the same information collected on the manual SI-3, however, it takes advantage of opportunities to electronically edit and skip unnecessary items. If the last day of the claim is more than 30 days after the current date, a pop-up screen asks the claimant to explain why the claim is being filed late. A claimant that files timely does not see the pop-up screen.

Upon completion of Questions 1 through 5, a review screen, which recaps the information provided, appears to give the claimant an opportunity to review and/or modify any of the information provided to that point. Question 6 provides for the certification of the information and the submission of the claim, or the deletion of the claim. It also enables a claimant who has already chosen payments by direct deposit to update bank information, or to switch to payment by check due to hardship.

The RRB proposes minor non-burden impacting changes to the form SI-3 (Internet):

• update the officer title and RRB zip code in the Paperwork Reduction Act/Privacy Act Notices section,

• update the “Estimation Completion Time” to 5 minutes, and

• update page 6 and page 7 with the correct zip code.

Form SI-7, Supplemental Doctor's Statement, is completed by a doctor to obtain medical evidence needed to supplement the medical information submitted by the employee's doctor on Form SI-1b. Supplemental medical evidence is needed when the medical evidence of record is insufficient to continue benefit payments. Instructions are printed on the form for the claimant and the claimant's doctor.

The claimant's name, address, last four digits of the social security number and the estimated ending date of sickness benefits are entered by the RRB on the front side. Codes relative to the claimant's medical and benefit information of record are also entered at the bottom on the reverse side (for RRB use only). Form SI-7 is also used by the RRB in situations where more detailed medical evidence is required to make a determination concerning a claimant's eligibility to work and his or her continued eligibility for sickness benefits. Form ID-7L, Notice to Claimant, is used to transmit Form SI-7 to the claimant in these cases.

The RRB proposes no changes to Form SI-7.

Form SI-8, Verification of Medical Information, is mailed to a doctor of a sickness benefit claimant to verify medical statements and information provided to the RRB by the railroad employee. The doctor is selected on the basis of a random sample check of Forms SI-1b and SI-7 received by the Office of Programs.

A photocopy of a medical report received by the RRB from the claimant's doctor is attached to the SI-8. The SI-8 requests the doctor to examine the medical report to verify that:

 the person cited in the report is a current patient;

 the doctor's office actually completed the report; and

 the report was accurate when made.

If, upon review of the medical report by the doctor, the report meets these three criteria, the doctor is instructed to discard both the Form SI-8 and the report itself. However, if the report does not meet one or more of these three criteria, the doctor is requested to provide an explanation or comments, along with appropriate report corrections in the bottom portion of the form. The completed SI-8 is then returned to the RRB in the return envelope provided.

Form SI-8 is also mailed on a routine basis to doctors who do not provide National Provider Identifiers on completed medical statements.

The RRB proposes no changes to Form SI-8.

Form ID-11A, Notice of Late Filing, is a computer-generated form letter which the RRB sends a claimant when Forms SI-1a/1b are not received within 30 days from the first day that sickness benefits were claimed. If the claimant tried to file the application on time but was unable to do so, the form requests the claimant provide an explanation in items 1‑9 on the form. Prior to releasing the form, the RRB prefills the earliest date for which the claimant could start receiving sickness benefits because of the late filing. 20 CFR 355.4 provides conditions for which the RRB considers a form “timely filed.” The RRB may consider circumstances “beyond a claimant’s control” as “timely filed” even if it was not received by the RRB during the prescribed time limits.

The RRB proposes no changes to Form ID-11A.

NOTE 1: Form UB-11, Sickness Benefits for Railroad Employees, is an informational booklet which contains copies of Forms SI-1a and SI-1b/SI-10, and a pre-addressed envelope to the Office of Programs at RRB headquarters. The booklet also contains the Paperwork Reduction Act and Privacy Act Notices for Forms SI-1a, SI‑1b, and SI-3 and instructions for the filing of sickness benefits and claims for this collection.

3. Planned use of improved information technology or technical/legal impediments to further burden reduction - Not practicable for Forms SI-1a, SI-1b, SI-7 and SI-8 as they are part of larger process that will not be automated. Not practicable for Forms ID-11a, because RRB initiates the form and it has pre-filled data. Form SI-3 is programmed for Internet processing.

4. Efforts to identify duplication - To our knowledge, this information collection does not duplicate any other information collection or another agency uses forms similar to Forms SI-1a, SI-1b, SI-3, SI-3 (Internet) SI-7, SI-8, or ID-11a.

5. Small business respondents - N.A.

6. Consequences of less frequent collection - Not applicable to Forms SI-1a, SI-1b, or ID-11A, since the RUIA requires a claimant to apply for benefits once during each spell of sickness. Consequently, less frequent collection of the information by these forms would be contrary to law. Under RRB regulations, a Form SI-3 must be filed for each 14-day registration period in which sick days are claimed. Failure to file a claim form would result in a loss of sickness benefits to the employee for that particular registration period. Also, not applicable to Form SI‑8 since the information obtained by this form is solicited only once. Less frequent use of Form SI-7 would result in erroneous benefit payments for days on which the claimant is able to work.

7. Special circumstances – None

8. Consultations outside the agency - In accordance with 5 CFR 1320.8(d), comments were invited from the public regarding the information collection. The notice to the public was published on page 36888 of the June 18, 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 Sick-ness 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 current and proposed burden for the information collection follows.

Current Burden

Form Number	Annual Responses	Time (Minutes)1/	Burden (Hours)
SI-1a (Employee)	15,700	10	2,617
SI-1b (Doctor)	15,700	8	2,093
SI-3 (Manual)	131,600	5	10,967
SI-3 (Internet)	61,350	5	5,113
SI-7	20,830	8	2,777
SI-8	26	5	2
ID-11A	518	4	35
Total	245,724		23,604

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.

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

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

15. Explanation for change in burden – N.A.

16. Time schedule data collection and publication - 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

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