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OMB Control No: 0720-0053	ICR Reference No: 202603-0720-003
Status: Received in OIRA	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	Date Submitted to OIRA: 03/31/2026

	Requested	Previously Approved
Expiration Date	36 Months From Approved	04/30/2026
Responses	420,000	420,000
Time Burden (Hours)	105,000	105,000
Cost Burden (Dollars)	2,466,450	2,007,600

ICR Summary of Burden

	Total Request	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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