Survivor Questionnaire

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form RL-94F (10-18) Survivor Questionnaire	Form and Instruction	Unchanged	Repair queued
Request OMB Approval of NonSubstantive Change to ICR 3220-0032_Signed.pdf	Justification for No Material/Nonsubstantive Change	Uploaded 2023-08-24	Available
3220-0032.docx	Supporting Statement A	Uploaded 2022-09-20	Available
Section 6 of the Railroad Retirement Act Of 1974.pdf	Supplementary Document	Uploaded 2019-09-26	Repair queued
20 CFR 234.pdf	Supplementary Document	Uploaded 2019-09-26	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
33842	Survivor Questionnaire	Form and Instruction	Unchanged

ICR Details

OMB Control No: 3220-0032	ICR Reference No: 202308-3220-007
Status: Active	Previous ICR Reference No: 202209-3220-002
Agency/Subagency: RRB	Agency Tracking No:
Title: Survivor Questionnaire
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/24/2023
	Date Received in OIRA: 08/24/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2026	01/31/2026	01/31/2026
Responses	5,450	0	5,450
Time Burden (Hours)	959	0	959
Cost Burden (Dollars)	0	0	0

---

Abstract: Under Section 6 of the Railroad Retirement Act, benefits are payable to the survivors or the estates of deceased railroad employees. The collection obtains information used to determine if and to whom benefits are payable; such as a widow(er) due survivor benefits, an executor of the estate, or a payer of burial expenses.

---

Authorizing Statute(s): US Code: 45 USC 231(f) et seq. Name of Law: Railroad Retirement Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 42217	07/14/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 57526	09/20/2022
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Survivor Questionnaire	RL-94F (XX-XX), RL-94F (10-18)	Survivor Questionnaire ,   Survivor Questionnaire

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	5,450	5,450	0	0	0	0
Annual Time Burden (Hours)	959	959	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $10,609

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 08/24/2023

---