View Information Collection Request (ICR) Package

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View ICR - OIRA Conclusion

OMB Control No: 0720-0053	ICR Reference No: 202603-0720-003
Status: Active	Previous ICR Reference No: 202301-0720-002
Agency/Subagency: DOD/DODOASHA	Agency Tracking No: 0720-0053
Title: Active Duty Dental Program Claim Form
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: 05/04/2026
	Date Received in OIRA: 03/31/2026
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2029	36 Months From Approved	05/31/2026
Responses	420,000	0	420,000
Time Burden (Hours)	105,000	0	105,000
Cost Burden (Dollars)	2,466,450	0	2,007,600

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	420,000	420,000	0
Annual Time Burden (Hours)	105,000	105,000	0
Annual Cost Burden (Dollars)	2,466,450	2,007,600	458,850

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:

Annual Cost to Federal Government: $2,466,450

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. No

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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