Information Collection

Railroad Unemployment Insurance Act Applications

IC 33857 under ICR 202308-3220-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form ID-11A (04-17) Railroad Unemployment Insurance Act Applications Form and Instruction
Form ID-11A (04-17) Railroad Unemployment Insurance Act Applications Form and Instruction
ID-11A (04-17) Requesting Reason for Late Filing of Sickness Benefit Form ID-11A (04-17).pdf Form and Instruction
ID-11A (04-17) Requesting Reason for Late Filing of Sickness Benefit Form ID-11A (04-17).pdf Form and Instruction
SI-3 (Internet)(10 Claim for Sickness Benefits Form SI-3 (Internet) (10-10).pdf Form and Instruction
SI-3 (Internet)(10 Claim for Sickness Benefits Form SI-3 (Internet) (10-10).pdf Form and Instruction
SI-1A (03-12) Application for Sickness Benefits Form SI-1A (03-12).pdf www.rrb.gov/pdf/PandS/ub11.pdf Form
SI-1A (03-12) Application for Sickness Benefits Form SI-1A (03-12).pdf www.rrb.gov/pdf/PandS/ub11.pdf Form
SI-3 (02-09) Claim for Sickness Benefits Form SI-3 (02-09).pdf Form
SI-3 (02-09) Claim for Sickness Benefits Form SI-3 (02-09).pdf Form
SI-3 (Internet) (x Claim for Sickness Benefits Form SI-3 (Internet) (xx-xx) - Proposed.pdf Form and Instruction
SI-3 (Internet) (x Claim for Sickness Benefits Form SI-3 (Internet) (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: Unchanged

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 335

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	ID-11A (04-17)	Requesting Reason for Late Filing of Sickness Benefit	Form ID-11A (04-17).pdf		No		Paper Only
Form and Instruction	SI-3 (Internet)(10-10)	Claim for Sickness Benefits	Form SI-3 (Internet) (10-10).pdf		Yes	Yes	Fillable Fileable Signable
Form	SI-1A (03-12)	Application for Sickness Benefits	Form SI-1A (03-12).pdf	http://www.rrb.gov/pdf/PandS/ub11.pdf	Yes	No	Printable Only
Form	SI-3 (02-09)	Claim for Sickness Benefits	Form SI-3 (02-09).pdf		No		Paper Only
Form and Instruction	SI-3 (Internet) (xx-xx)	Claim for Sickness Benefits	Form SI-3 (Internet) (xx-xx) - Proposed.pdf		Yes	Yes	Fillable Fileable Signable

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: 209,168	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 29 %

	Approved	Previously Approved
Annual Number of Responses for this IC	209,168	209,168
Annual IC Time Burden (Hours)	18,732	18,732
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.