3220-0036

OMB No. 3220-0036

Justification

Supplemental Information on Accident and Insurance

RRB Forms SI-1c, SI-5, ID-3s, ID-3s (Internet), ID-3s-1, ID-3u, ID-3u (Internet),and ID-30k

1. Circumstances of information collection - Under Section 12(o) of the Railroad Unemployment Insurance Act (RUIA) (45 U.S.C. 362(o)) the Railroad Retirement Board (RRB) is entitled to reimbursement of the sickness benefits paid to a railroad employee if the employee receives a sum or damages for the same infirmity for which the benefits were paid.

Section 2(f) of the RUIA (45 U.S.C. 231a) requires that employers reimburse the RRB for benefits paid to an employee for days for which salary, wages, pay for time lost or other remuneration is later determined to be payable. Reimbursements under section 2(f) generally result from the award of pay for time lost or the payment of guaranteed wages. The RUIA prescribes that the amount of benefits paid be deducted and held by the employer in a special fund for reimbursement to the RRB.

The procedures for recovery of such benefits are prescribed in 20 CFR 340 and 341.

2. Purposes of collecting/consequences of not collecting the information - Under 20 CFR 341.4, an employee who has applied for sickness benefits and has reported an infirmity that was caused by a third party is to provide the name and address of the person or company who is alleged to have caused the infirmity. Moreover, the employee is to provide whatever details are reasonably needed so that the RRB may establish its’ lien upon any sum or damages paid or payable to that employee. Further, under 20 CFR 341.6 when a person or company makes a settlement or must satisfy a final judgment based on any injury for which the employee received sickness benefits, the person or company must notify the RRB of the settlement or judgment. That notice must be in writing and submitted within 5 days of the settlement or final judgment. The notification should contain the amount, the date, and the amount withheld to satisfy the RRB's lien.

Similarly, if a payment subject to section 2(f) of the RUIA is to be made, employers must contact the RRB to obtain the amount of benefits paid for the period so that the proper reimbursement is made to the RRB.

The RRB forms currently used for these purposes are Forms SI-1c, SI-5, ID-3s, ID-3s (Internet), ID-3s-1, ID‑3u, ID-3u (Internet), and ID‑30k. Details about each of the forms follow.

Manual Forms

Form SI-1c, Supplemental Information on Accident and Insurance, is used by the RRB to obtain specific information from a claimant about the identity of the person or persons who may be responsible for the payment of damages to the claimant. Form SI-1c is used when the application for sickness benefits, Form SI-1a, Application for Sickness Benefits (OMB No. 3220-0039), or another source, indicates that the claimant may receive a sum or damages for the same injury for which sickness benefits are claimed and the person or company to whom a notice of lien should be sent is not on record. If the claimant did not complete Section C – Accident and Insurance Information, on the SI-1A, do we need to send the claimant an SI-1C to get the information which they neglected to complete Completion of Form SI‑1c is self-explanatory. Note: The SI-1C is only used when the applicant skips the questions on the SI-1A and the RRB determines that the information is needed.

The RRB proposes no changes to Form SI-1c.

Form SI-5, Report of Payments to Employee Claiming Sickness Benefits Under the Railroad Unemployment Insurance Act, is used by the RRB to obtain the information needed to determine the amount of reimbursement to which the RRB is entitled from a railroad employer. Form SI-5 obtains information not only on sums or damages paid or payable to the employee, but also on pay for time lost and workers' compensation, since under sections 2(f) and 4(a-1)(ii) of the RUIA, these payments can affect the amount of reimbursement. The form is mailed to the railroad employer who could be liable for the personal injury settlement based on information supplied by the employee on Form SI‑1a, Application for Sickness Benefits, or Form SI-1c.

Forms SI-5 is computer generated. Each form is accompanied by a computer-generated Form ID-30B, Notice of Lien, which serves as a transmittal letter. The employee's name and other identifying information on the ID-30B and SI-5 are pre-filled by the RRB. Completion of the form is self-explanatory.

The RRB proposes no changes to Form SI-5.

Form ID-3s, Request for Lien Information - Report of Settlement, is used by a railroad employer to obtain Section 12(o) information and to report personal injury settlements by facsimile machine. The form is sent by a railroad employer to the RRB when a personal injury claim is nearing settlement and information regarding the amount of the RRB's lien is required so that proper reimbursement can be made to the RRB. Based on identifying information entered on the form by the railroad employer in Items 1-8, the RRB computes the amount of the lien, enters it in Items 9 and 10, and then transmits the completed form to the railroad employer by fax. The form can also be used to provide notice of a settlement to the RRB.

We estimate that we fax the completed Form ID-3s in over 75% of the cases involving employer requests for lien information. The remaining employer requests are made by telephone. The identifying information provided by employers when making telephone requests is identical to the information provided by employers on Form ID-3s. Completion of Form ID-3s is self-explanatory.

The RRB proposes the following minor non-burden impacting editorial changes to manual Form ID-3s:

• change PRA/PA notice to update the officer title and

• add RRB zip code.

Form ID-3s-1, Lien Information under Section 12(o) of the RUIA, is similar to Form ID‑3s, and is used by an attorney and/or the insurer responsible for paying personal-injury damages to the railroad employee for third-party liability cases. The form is used to obtain Section 12(o) information from the RRB and provides for the reporting of personal-injury settlements by facsimile machine (fax). Internal RRB reviews show that a small group of attorneys and insurance companies represent a substantial number of railroad employees or liable parties where the provisions of section 12(o) are applicable. The form is for their use in order to provide improved customer service. Initially, an attorney or insurer requesting lien information completes Items 1 through 5 of Form ID-3s-1 and then transmits the form via fax to the RRB. The RRB provides the lien amount information and then sends a fax of the completed Form ID‑3s‑1 back to the inquirer.

We estimate that we fax the completed Form ID-3s-1 in about 80% of the cases involving attorney/insurer requests for lien information. The remaining attorney/insurer requests are made by telephone. The identifying information provided by the attorneys/insurers when making telephone requests is identical to the information provided by the attorneys/insurers on Form ID-3s-1. Completion of Form ID-3s-1 is self-explanatory.

The RRB proposes no changes to Form ID-3s-1.

Form ID-3u, Request for Section 2(f) Information, is used by railroad employers to obtain Section 2(f) information by facsimile machine (fax). The form is transmitted by railroad employers to the RRB when salary, wages, pay for time lost or other remuneration is determined to be payable for days for which benefits under the RUIA may also have been paid to an individual. Based on identifying information entered on the form by the railroad employer in Items 1‑7, the RRB computes the amount of benefits to be reimbursed, enters it in Item 8, and returns the completed form to the railroad employer by fax.

We estimate that we fax the completed Form ID‑3u in over 80% of the cases involving employer requests for section 2(f) information. The remaining employer requests are made by telephone. Completion of Form ID-3u is self-explanatory.

The RRB proposes the following minor non-burden impacting editorial changes to manual Form ID-3u:

• change PRA/PA notice to update the officer title and

• update RRB zip code.

Form ID-30k, Notice to Request Supplemental Information on Injury or Illness, is released by the RRB along with transmittal letter ID-30D, when notice of a monetary settlement (Form SI-5) has not been received from the responsible third party after a year has elapsed and is used to obtain up-to-date information from the claimant regarding the status of the monetary settlement. If, after approximately 6 months, the first ID-30k has not been completed and returned to the RRB, a follow-up ID-30k is sent to the claimant. Completion of Form ID-30k is self-explanatory.

The RRB proposes no changes to Form ID-30k.

Electronic Forms

Form ID-3s (Internet), Request for Lien Information – Report of Settlement, is submitted by employers who have obtained access to the RRB’s Employer Reporting System (ERSNet).

Access to ERSNet is granted only to employers and their employees who have completed RRB Form BA‑12, Application for Employer Reporting Internet Access (3220-0008), which provides information used by the RRB to evaluate, grant, and document the level of access requested (view/only, data entry/modification or approval/submission). Once the appropriate access is secured, an employer can complete and submit Form ID-3s (Internet) online.

Although the ID-3s (Internet) collects essentially the same information as the other approved versions of Form ID-3s, it consists of a screen that collects the necessary information and provides for the required notices and certifications, as well as help messages designed to guide the user through the system and complete a successful transaction.

Railroad employers submit the ID-3s (Internet) when a personal injury claim is nearing settlement and information regarding the amount of the RRB's lien is required, so that proper reimbursement can be made to the RRB. Based on identifying information entered on the form by the railroad employer in Items 1-8, the RRB computes the amount of the lien, enters it in Item 14, and responds back to the employer via ERSNet. The form can also be used to provide notice of a settlement to the RRB.

The RRB proposes no changes to Form ID-3s (Internet).

Form ID-3u (Internet), Request for Section 2(f) Information, is submitted by employers who have obtained access to the RRB’s Employer Reporting System (ERSNet).

The ID-3u (Internet) is not a form in the traditional sense but more of a process. Although it collects essentially the same information as the other approved versions of Form ID-3u, it consists of a screen that collects the necessary information and provides for the required notices and certifications, as well as help messages designed to guide the user through the system and complete a successful transaction.

Access to ERS is granted only to employers and their employees who have completed RRB Form BA‑12, Application for Employer Reporting Internet Access (3220-0008), which provides information used by the RRB to evaluate, grant, and document the level of access requested (view/only, data entry/modification or approval/submission). Once the appropriate access is secured, an employer can complete and submit Form ID-3u (Internet) online.

The RRB proposes no changes to Form ID-3u (Internet).

3. Planned use of improved information technology or technical/legal impediments to further burden reduction - Adding information technology to Forms SI‑5 and ID‑3s-1 are not practical because the forms are initiated by the RRB with pre-filled data and are not cost-effective due to low volume. Form SI-1c is part of a larger process that will not be automated.

4. Efforts to identify duplication – This information collection does not duplicate any other RRB information collection and to our knowledge, no other agency uses forms similar to Forms SI-1c, SI-5, ID-3s, ID-3s (Internet), ID-3s-1, ID-3u, ID-3u (Internet), and ID-30k.

5. Small business respondents - N.A.

6. Consequence of less frequent collection - Not applicable since the information is obtained only once.

7. Special circumstances - None

8. Public comments/consultations outside the agency - In accordance with 5 CFR 1320.8(d), comments were invited from the public regarding the information collection. The notice to the public was published on page 29377 of the April 22, 2024, Federal Register. No comments or requests for additional information were received.

9. Payments or gifts to respondents - None.

10. Confidentiality - Privacy Act System of Records, RRB-21, Railroad Unemployment and Sickness Insurance Benefit System - RRB. In accordance with OMB Circular M-03-22, a Privacy Impact Assessment for this information collection was completed and can be found at https://www.rrb.gov/sites/default/files/2017-06/PIA-BPO.pdf.

11. Sensitive questions - N.A.

12. Estimate of respondent burden - The current and proposed burden for the collection is as follows.

Current Burden

Form Number	Annual Responses	Time (Minutes)	Burden (Hours)
SI-1c	1,700	5	142
SI-5	100	5	8
ID-3s (paper & telephone)	2,000	3	100
ID-3s (Internet)	2,000	3	100
ID-3s-1 (paper & telephone)	1,200	3	60
ID-3u (paper & telephone)	1,000	3	50
ID-3u (Internet)	800	3	40
ID-30k	100	5	8
Total	8,900		508

Proposed Burden

Form Number	Annual Responses	Time (Minutes)1/	Burden (Hours)
SI-1c	890	5	74
SI-5	10	5	1
ID-3s (paper & telephone)	1,700	3	85
ID-3s (Internet)	4,853	3	243
ID-3s-1 (paper & telephone)	1,845	3	93
ID-3u (paper & telephone)	152	3	8
ID-3u (Internet)	596	3	30
ID-30k	24	5	3
Total	10,070		538

1/The RRB has been collecting the information on these forms since OMB approved the information collection. Based on a sampling done when the form was originally created, the office calculated the estimated time, which includes time for getting the needed data and reviewing the completed form.

Responses Hours

Total Burden Change +1,170 +30

Program Change +1,170 +30

13. Estimated annual cost to respondents or record keepers - N.A.

13. Estimate of cost to Federal government - N.A.

13. Explanation for change in burden – The overall burden estimated for the collection has increased by 1,167 from 8,900 to 10,067 and the burden hours have increased by 30 hours from 508 to 538 hours.

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 amount of annual responses.

We estimate the 2,000 responses currently received using the internet Form ID-3s will now increase to 4,853, an increase of 2853 and the burden changed from100 to 243, an increase of 143.

Due to the increased use of the Form ID-3s-1, we have increased the responses from 1200 to 1845, an increase of 645; and the burden hours increased by 33, from 60 to 93.

Due to the decreased use of the ID-30k, we have decreased the responses by 76, from 100 to 24 and the burden hours by 6, from 8 to 2.

Due to lesser use of paper and telephone Form ID-3u, we have decreased the responses from the versions by 848, from 1000 to 52; and the burden hours by 42 from 50 to 8. We have also decreased the responses from the internet version by 204, from 800 to 596 and the burden hours by 10, from 40 to 30.

13. Time schedule for data collection and publication - The results of this collection will not be published.

13. Request not to display OMB expiration date - The RRB started an extensive multi-year IT Modernization Initiative at the beginning of Fiscal Year 2019 to transform our operations into the 21st Century using multiple contractor services to improve mission performance, expand service capabilities, and strengthen cybersecurity. We provided OMB with a consolidated project timeline.

Given that the forms in this collection are seldom revised; the costs associated with redrafting, reprinting, and distributing forms to keep the appropriate OMB expiration date in place; and our desire to reevaluate after the completion of the modernization project, the RRB requests the authority to not display the expiration date on the forms.

13. Exceptions to Certification Statement - None