Information Collection

Railroad Unemployment Insurance Act Applications

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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form SI-1b (08-21) Railroad Unemployment Insurance Act Applications	Form and Instruction
Form SI-1b (08-21) Statement of Sickness Railroad Unemployment Insurance Act Applications	Form and Instruction
Form SI-7 (08-23) Supplemental Doctor's Statement Railroad Unemployment Insurance Act Applications	Form and Instruction
Form SI-8 (08-21) Verification of Medical Information 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

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Electronic Capability
Form and Instruction	SI-1b (08-21)	No	Printable Only
Form and Instruction	SI-7 (08-23)	No	Paper Only
Form and Instruction	SI-8 (08-21)	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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
UB-11, Sickness Benefits for Railroad Employees		01/10/2025
SI-10, Statement of Authority to ACt for Employee		01/10/2025

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

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