Information Collection

Railroad Unemployment Insurance Act Applications

IC 179107 under ICR 202411-3220-016 · OMB 3220-0039.

Documents and Forms

Document Name Document Type
Form SI-1b (08-21) Railroad Unemployment Insurance Act Applications Form and Instruction
SI-1b (08-21) Statement of Sickness Form SI-1b (08-21).pdf Form and Instruction
SI-1b (08-21) Statement of Sickness Form SI-1b (08-21).pdf Form and Instruction
SI-7 (08-23) Supplemental Doctor's Statement Form SI-7 (08-23).pdf Form and Instruction
SI-7 (08-23) Supplemental Doctor's Statement Form SI-7 (08-23).pdf Form and Instruction
SI-8 (08-21) Verification of Medical Information Form SI-8 (08-21).pdf Form and Instruction
SI-8 (08-21) Verification of Medical Information Form SI-8 (08-21).pdf Form and Instruction
UB-11 (08-21).pdf UB-11, Sickness Benefits for Railroad Employees IC Document
UB-11 (08-21).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: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 20 CFR 355

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	SI-1b (08-21)	Statement of Sickness	Form SI-1b (08-21).pdf	No	Printable Only
Form and Instruction	SI-7 (08-23)	Supplemental Doctor's Statement	Form SI-7 (08-23).pdf	No	Paper Only
Form and Instruction	SI-8 (08-21)	Verification of Medical Information	Form SI-8 (08-21).pdf	No	Paper Only

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: 23,354	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	23,354	-13,202	36,556
Annual IC Time Burden (Hours)	1,988	-2,884	4,872
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
UB-11, Sickness Benefits for Railroad Employees	UB-11 (08-21).pdf	01/10/2025
SI-10, Statement of Authority to ACt for Employee	Form SI-10 (05-17) stand alone.pdf	01/10/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.