View Information Collection Request (ICR) Package
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OMB Control No:
0720-0003
ICR Reference No:
202509-0720-001
Status:
Received in OIRA
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
Date Submitted to OIRA:
11/20/2025
Requested
Previously Approved
Expiration Date
36 Months From Approved
Responses
188,090
0
Time Burden (Hours)
47,023
0
Cost Burden (Dollars)
1,535,755
0
Abstract:
This information is completed by TRICARE beneficiaries suffering from personal injuries and receiving medical care at Government expense. This information is necessary in the assertion of the Government's right to recover under the Federal Medical Care Recovery Act. The data is used in the evaluation and processing of these claims.
Authorizing Statute(s):
US Code:
42 USC 2651-2653
Name of Law: The Federal Medical Care Recovery Act
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:
90 FR 34258
07/21/2025
30-day Notice:
Federal Register Citation:
Citation Date:
90 FR 45753
09/23/2025
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
Statement of Personal Injury: Possible Third Party Liability
DD2527
Statement of Personal Injury: Possible Third Party Liability
ICR Summary of Burden
Total Request
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
188,090
0
0
188,090
0
0
Annual Time Burden (Hours)
47,023
0
0
47,023
0
0
Annual Cost Burden (Dollars)
1,535,755
0
0
1,535,755
0
0
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
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:
11/20/2025
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