PILOT TEST OF CHAMPUS PREPAID HEALTH BENEFIT DEMONSTRATION - EMPLOYER HEALTH BENEFIT FORM

ICR 198204-0704-006

OMB: 0704-0165

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0704-0165 198204-0704-006
Historical Active
DOD/DODDEP
PILOT TEST OF CHAMPUS PREPAID HEALTH BENEFIT DEMONSTRATION - EMPLOYER HEALTH BENEFIT FORM
New collection (Request for a new OMB Control Number)   No
Regular
Approved without change 05/06/1982
Retrieve Notice of Action (NOA) 04/14/1982
  Inventory as of this Action Requested Previously Approved
12/31/1982 12/31/1982
144 0 0
24 0 0
0 0 0

A PILOT TEST OF THE CHAMPUS PREPAID HEALTH BENEFIT DEMONSTRATION IS BEING CONDUCTED IN PORTLAND, OREGON. IN ORDER TO ASSESS THE FREQUENCY AND UNDERLYING FACTORS WHICH CAUSE CHAMPUS ELIGIBLES TO DISCONTINUE HEALTH BENEFIT COVERAGE THROUGH THEIR EMPLOYERS WHEN PARTICIPATING IN THIS DEMONSTRATION, EMPLOYERS WILL BE REQUESTED TO PROVIDE HEALTH BENEFIT INFORMATION.

None
None


No

1
IC Title Form No. Form Name
PILOT TEST OF CHAMPUS PREPAID HEALTH BENEFIT DEMONSTRATION - EMPLOYER HEALTH BENEFIT FORM

  Total Approved 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 144 0 0 144 0 0
Annual Time Burden (Hours) 24 0 0 24 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
No

$0
No
No
Uncollected
Uncollected
Uncollected
Uncollected

  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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
04/14/1982


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