View Information Collection Request (ICR) Package
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View Information Collection (IC) List
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0720-0028
ICR Reference No:
201309-0720-001
Status:
Historical Active
Previous ICR Reference No:
200911-0720-004
Agency/Subagency:
DOD/DODOASHA
Agency Tracking No:
Title:
TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request
Type of Information Collection:
Reinstatement with change of a previously approved collection
Common Form ICR:
No
Type of Review Request:
Regular
OIRA Conclusion Action:
Approved without change
Conclusion Date:
02/14/2014
Retrieve Notice of Action (NOA)
Date Received in OIRA:
10/22/2013
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
02/28/2017
36 Months From Approved
Responses
25,065
0
0
Time Burden (Hours)
2,924
0
0
Cost Burden (Dollars)
75,446
0
0
Abstract:
The collection instrument is used to collect information from eligible beneficiaries who want to enroll in or disenroll from TRICARE Plus. TRICARE Plus is an enrollment option for TRICARE beneficiaries who want an affiliation with a primary care provider at a Military Treatment Facility (MTF) and are either ineligible for TRICARE Prime or prefer a more limited relationship (primary care only). The collection instrument is used by contractors to determine beneficiary eligibility and to identify the selection of a health option.
Authorizing Statute(s):
US Code:
10 USC 1099
Citations for New Statutory Requirements:
None
Associated Rulemaking Information
RIN:
Stage of Rulemaking:
Federal Register Citation:
Date:
Not associated with rulemaking
Federal Register Notices & Comments
60-day Notice:
Federal Register Citation:
Citation Date:
77 FR 71176
11/29/2012
30-day Notice:
Federal Register Citation:
Citation Date:
78 FR 59341
09/26/2013
Did the Agency receive public comments on this ICR?
No
Number of Information Collection (IC) in this ICR:
1
IC Title
Form No.
Form Name
TRICARE Plus Enrollment Application TRICARE Plus Disenrollment Request
DD Form 2854, DD From 2852
TRICARE Plus Enrollment Application
,
TRICARE Plus Disenrollment Form
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
25,065
0
0
0
0
25,065
Annual Time Burden (Hours)
2,924
0
0
0
-9
2,933
Annual Cost Burden (Dollars)
75,446
0
0
0
75,446
0
Burden increases because of Program Change due to Agency Discretion:
No
Burden Increase Due to:
Burden decreases because of Program Change due to Agency Discretion:
No
Burden Reduction Due to:
Short Statement:
Adjustment is due to reinstatement of a currently approved collection. Burden hours adjustments are due to the ever changing access to TRICARE Plus. The only changes to the forms were the Privacy Act Statement and the Agency Disclosure Notice.
Annual Cost to Federal Government:
$216,561
Does this IC contain surveys, censuses, or employ statistical methods?
No
Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002?
No
Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]?
No
Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]?
No
Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)?
No
Is this ICR related to the Pandemic Response?
Uncollected
Agency Contact:
Frederick Licari 571 372-0493 frederick.c.licari.civ@mail.mil
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
10/22/2013
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