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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
Supplemental Information on Accident and Insurance
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 341
20 CFR 340
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
SI-5 (12-93)
Report of Payments to Employee Claiming Sickness Benefits Under the RUIA
Form SI-5 (12-93).pdf
No
Paper Only
Form and Instruction
ID-3S (03-09)
Request for Lien Information; Report of Settlement
Form ID-3S (03-09).pdf
Yes
Yes
Fillable Fileable Signable
Form and Instruction
ID-3S-1 (08-17)
Lien Information Under Section 12(o) of the RUIA
Form ID-3S1 (08-17).pdf
No
Paper Only
Form and Instruction
ID-3U (03-09)
Request for Section 2(f) Information
Form ID-3u (03-09).pdf
Yes
Yes
Fillable Fileable Signable
Form and Instruction
ID-30K-1 (05-17)
Request for Supplemental Information on Injury or Illness - 3rd party
Form ID-30K-1 (05-17).pdf
No
Paper Only
Form and Instruction
ID-3S (Internet) (09-14)
Request for Lien Information; Report of Settlement
Form ID-3S (Internet) (09-14) Screens.pdf
https://secure.rrb.gov/ERSNet/login.aspx
Yes
Yes
Fillable Fileable
Form and Instruction
ID-3U (Internet) (09-14)
Request for Section 2(f) Information
Form ID-3U (Internet) (09-14) Screens.pdf
https://secure.rrb.gov/ERSNet/login.aspx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Litigation and Judicial Activities
Subfunction:
Resolution Facilitation
Privacy Act System of Records
Title:
RRB-21, Railroad Unemployment and Sickness Benefit System
FR Citation:
79 FR 58874
Number of Respondents:
1,325
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
77 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
9,672
0
-600
0
0
10,272
Annual IC Time Burden (Hours)
486
0
-30
0
0
516
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Notice of Lien Transmittal Letter
Form ID-30B-1 (08-17).pdf
09/22/2017
Notice of Lien Transmittal Letter
Form ID-30B-2 (08-17).pdf
09/22/2017
Notice of Lien Transmittal Letter
Form ID-30B (08-12).pdf
07/16/2014
Program Letter 2006-05, E-Mail Requests for 12(o) and 2(f) reimbursements
Program Letter (06-05) for E-Mail requests.pdf
09/12/2017
ID-30D-1, Request for Information on Injury or Illness
Form ID-30D-1 (04-06).pdf
07/16/2014
Program Letter 2007-02, Employer Responsibilities under 12(o) and 2(f)
Program Letter (07-02) for ERs under 2(f) & 12(o).pdf
09/12/2017
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.