View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0720-0003	ICR Reference No: 202509-0720-001
Status: Active	Previous ICR Reference No: 202203-0720-005
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Statement of Personal Injury: Possible Third Party Liability
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/12/2026
	Date Received in OIRA: 11/20/2025
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2029	36 Months From Approved
Responses	188,090	0	0
Time Burden (Hours)	47,023	0	0
Cost Burden (Dollars)	1,535,755	0	0

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	188,090	188,090
Annual Time Burden (Hours)	47,023	47,023
Annual Cost Burden (Dollars)	1,535,755	1,535,755

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: There has been no change in burden since the last approval.

Annual Cost to Federal Government: $1,030,263

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? No

Agency Contact: Amanda Grifka 555 555-5555 amanda.b.grifka.civ@health.mil

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