View Information Collection Request (ICR) Package

OMB Control No: 0720-0061	ICR Reference No: 201712-0720-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOD/DODOASHA	Agency Tracking No: 0720-AAHG
Title: TRICARE Select
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR: No
Type of Review Request: Emergency	Approval Requested By: 12/22/2017
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/22/2017
	Date Received in OIRA: 12/08/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2018	6 Months From Approved
Responses	99,300	0	0
Time Burden (Hours)	24,825	0	0
Cost Burden (Dollars)	179,733	0	0

Abstract: The information collection is necessary to obtain non-active duty TRICARE beneficiary’s personal information needed to: (1) complete his/her enrollment into the “new” TRICARE Select health plan option as created by the National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2017, (2) dis-enroll a beneficiary, or (3) change the beneficiary’s enrollment (e.g., address, add a dependent, report other health insurance. This information is required to ensure the beneficiary’s benefits and claims are administered based on their plan of choice.

Emergency Justfication: Complying with the normal clearance procedures is likely to delay or disrupt the collection of information, and could have a negative impact on our service members, and compliance with new statute requirements, effective as of January 1, 2018. The National Defense Authorization Act for FY 2017 has mandated that two key aspects of the TRICARE system, TRICARE Extra and TRICARE Standard, which will be terminated as of December 31, 2017, are to be replaced by TRICARE Select. This information collection is necessary to obtain non-active duty TRICARE beneficiary’s personal information needed to complete his/her enrollment into the “new” TRICARE Select health plan option as created by the National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2017, dis-enroll a beneficiary, or change the beneficiary’s enrollment. This information is required to ensure the beneficiary’s benefits and claims are administered based on their plan of choice. The information collection is essential to the mission of the Department.

Authorizing Statute(s): PL: Pub.L. 114 - 328 701, 706, 715, 718, and 729 Name of Law: National Defense Authorization Act for FY 2017

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
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 57962	12/08/2017
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 Select Enrollment, Disenrollment, and Change Form	DD Form 3043

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	99,300	99,300
Annual Time Burden (Hours)	24,825	24,825
Annual Cost Burden (Dollars)	179,733	179,733

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection with a new associated burden.

Annual Cost to Federal Government: $179,891

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

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: Ben McAlduff 480 316-1398 benjamin.d.mcalduff.ctr@mail.mil

View ICR - OIRA Conclusion