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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request
Agency IC Tracking Number:
Is this a Common Form?
No
IC Status:
Modified
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
32 CFR 199
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
DD Form 2853
TRICARE Plus Enrollment Application
dd2853_20170531.pdf
Yes
No
Fillable Printable
Form
DD Form 2854
TRICARE Plus Disenrollment Request
dd2854_20170531.pdf
Yes
No
Fillable Printable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Defense and National Security
Subfunction:
Operational Defense
Privacy Act System of Records
Title:
Military Health Information System
FR Citation:
78 FR 69076
Number of Respondents:
3,305
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
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
3,305
0
-21,760
0
25,065
0
Annual IC Time Burden (Hours)
386
0
-2,538
0
2,924
0
Annual IC Cost Burden (Dollars)
2,776
0
-72,670
0
75,446
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.