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OMB Control No: 0704-0650	ICR Reference No: 202512-0704-002
Status: Received in OIRA	Previous ICR Reference No: 202212-0704-001
Agency/Subagency: DOD/DODDEP	Agency Tracking No: 0704-AQFL
Title: Qualified Facility List Application Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular	Date Submitted to OIRA: 02/25/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	02/28/2026
Responses	250	250
Time Burden (Hours)	250	250
Cost Burden (Dollars)	5,243	4,858

Annual Cost to Federal Government: $5,846

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. 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? No

Agency Contact: Nicholas Schuff 757 817-7203 nicholas.a.schuff.ctr@mail.mil

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