Supplemental Information on Accident and Insurance

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form ID-30K (05-17) Notice to Request Supplemental Information on Injury or Illness	Form	Modified	Repair queued
Form SI-1C (04-17) Supplemental Information on Accident and Insurance	Form and Instruction	Modified	Available
Form SI-1C (04-17) Supplemental Information on Accident and Insurance	Form and Instruction	Modified	Repair queued
Form ID-3U Request for Section 2(f) Information	Form and Instruction	Modified	Available
Form ID-3S (xx-xx) Request for Lien Information: Report of Settlement	Form and Instruction	Modified	Available
Form ID-3U (Internet) ( Request for Section 2(f) Information	Form and Instruction	Modified	Available
Form ID-3S (Internet) ( Request for Lien Information; Report of Settlement	Form and Instruction	Modified	Available
Form ID-3U (03-09) Request for Section 2(f) Information	Form and Instruction	Modified	Available
Form ID-3S-1 (08-17) Lien Information Under Section 12(o) of the RUIA	Form and Instruction	Modified	Available
Form ID-3S (03-09) Request for Lien Information; Report of Settlement	Form and Instruction	Modified	Available
Form SI-5 (12-93) Report of Payments to Employee Claiming Sickness Benefits Under the RUIA	Form and Instruction	Modified	Repair queued
Form SI-5 (12-93) Supplemental Information on Accident and Insurance	Form and Instruction	Modified	Repair queued
3220-0036.docx	Supporting Statement A	Uploaded 2024-06-25	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
33850	Supplemental Information on Accident and Insurance	Form	Modified	Notice to Request Supplemental Information on Injury or Illness
33850	Supplemental Information on Accident and Insurance	Form and Instruction	Modified	Supplemental Information on Accident and Insurance
33850	Supplemental Information on Accident and Insurance	Form and Instruction	Modified
187866	Supplemental Information on Accident and Insurance	Form and Instruction	Modified	Request for Section 2(f) Information
187866	Supplemental Information on Accident and Insurance	Form and Instruction	Modified	Request for Lien Information: Report of Settlement
187866	Supplemental Information on Accident and Insurance	Form and Instruction	Modified	Request for Section 2(f) Information
187866	Supplemental Information on Accident and Insurance	Form and Instruction	Modified	Request for Lien Information; Report of Settlement
187866	Supplemental Information on Accident and Insurance	Form and Instruction	Modified	Request for Section 2(f) Information
187866	Supplemental Information on Accident and Insurance	Form and Instruction	Modified	Lien Information Under Section 12(o) of the RUIA
187866	Supplemental Information on Accident and Insurance	Form and Instruction	Modified	Request for Lien Information; Report of Settlement
187866	Supplemental Information on Accident and Insurance	Form and Instruction	Modified	Report of Payments to Employee Claiming Sickness Benefits Under the RUIA
187866	Supplemental Information on Accident and Insurance	Form and Instruction	Modified

ICR Details

OMB Control No: 3220-0036	ICR Reference No: 202406-3220-005
Status: Active	Previous ICR Reference No: 202011-3220-001
Agency/Subagency: RRB	Agency Tracking No:
Title: Supplemental Information on Accident and Insurance
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/21/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/27/2024
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2027	36 Months From Approved	08/31/2024
Responses	10,070	0	8,900
Time Burden (Hours)	538	0	508
Cost Burden (Dollars)	0	0	0

---

Abstract: The Railroad Unemployment Insurance Act provides for the recovery of sickness benefits paid if an employee receives a settlement for the same injury for which benefits were paid. The collection obtains information that is needed to determine the amount of the RRB's reimbursement from the person or company responsible for such payments.

---

Authorizing Statute(s): US Code: 45 USC 362(l) Name of Law: Railroad Unemployment Insurance Act
   US Code: 45 USC 362(o) Name of Law: Railroad Unemployment Insurance 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:
	89 FR 29377	04/22/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 53464	06/26/2024
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Supplemental Information on Accident and Insurance	SI-1C (04-17), ID-30K (05-17)	Supplemental Information on Accident and Insurance ,   Notice to Request Supplemental Information on Injury or Illness
Supplemental Information on Accident and Insurance	ID-3S (xx-xx), ID-3U, SI-5 (12-93), ID-3S-1 (08-17), ID-3S (03-09), ID-3U (03-09), ID-3S (Internet) (09-14), ID-3U (Internet) (09-14)	Report of Payments to Employee Claiming Sickness Benefits Under the RUIA ,   Request for Lien Information; Report of Settlement ,   Lien Information Under Section 12(o) of the RUIA ,   Request for Section 2(f) Information ,   Request for Lien Information; Report of Settlement ,   Request for Section 2(f) Information ,   Request for Lien Information: Report of Settlement ,   Request for Section 2(f) Information

---

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	10,070	8,900	0	1,170	0	0
Annual Time Burden (Hours)	538	508	0	30	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This increase is due to the increase in use of Form ID-3u (internet) for job protection payments in the rail industry; the increased use of Form ID-3s-1 (paper & telephone), and improved tracking capabilities that allow the RRB to more accurately determine the number of annual responses. Due to improved tracking capabilities that allow the RRB to more accurately determine the number of annual responses there is a less reporting usage of Forms SI-1C and ID-30K.

---

Annual Cost to Federal Government: $0

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: 06/27/2024

---