View Information Collection Request (ICR) Package

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: 0720-0006	ICR Reference No: 201808-0720-001
Status: Historical Active	Previous ICR Reference No: 201501-0720-001
Agency/Subagency: DOD/DODOASHA	Agency Tracking No: 0720-0006
Title: TRICARE DoD/CHAMPUS Medical Claim Patient's Request for Medical Payment
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/16/2018
	Date Received in OIRA: 08/30/2018
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2021	36 Months From Approved	10/31/2018
Responses	830,000	0	774,000
Time Burden (Hours)	207,500	0	193,500
Cost Burden (Dollars)	1,504,375	0	4,992,300

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Adjustment in Estimate
Annual Number of Responses	830,000	774,000	56,000
Annual Time Burden (Hours)	207,500	193,500	14,000
Annual Cost Burden (Dollars)	1,504,375	4,992,300	-3,487,925

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: Based on previous respondent data captured, the estimated number of responses and time burden has increased. The cost burden has decreased due to a recalculation of respondent wages.

Annual Cost to Federal Government: $1,502,300

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: Kira Starks 571 372-4529 danikquia.k.starks.ctr@mail.mil

Something went wrong when downloading this file. If you have any questions, please send an email to risc@gsa.gov.