CHAMPUS CHOICE ENROLLMENT FORM

ICR 198503-0704-002

OMB: 0704-0162

Federal Form Document

Forms and Documents
Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
IC ID
Document
Title
Status
108757 Migrated
ICR Details
0704-0162 198503-0704-002
Historical Active 198203-0704-005
DOD/DODDEP
CHAMPUS CHOICE ENROLLMENT FORM
Revision of a currently approved collection   No
Regular
Approved without change 05/07/1985
Retrieve Notice of Action (NOA) 03/07/1985
  Inventory as of this Action Requested Previously Approved
04/30/1988 04/30/1988 04/30/1985
800 0 12,000
264 0 3,000
0 0 0

THE CHAMPUS CHOICE ENROLLMENT FORM IS USED BY PROSPECTIVE CHAMPUS CHOI ENROLLEES. THE REQUESTED INFORMATION ESTABLISHES THE ELIGIBILITY OF ENROLLEES, THE PLAN SELECTED, THE METHOD OF PAYMENT AND THE EFFECTIVE DATE OF PARTICIPATION IN THE PREPAID HEALTH CARE PLAN.

None
None


No

1
IC Title Form No. Form Name
CHAMPUS CHOICE ENROLLMENT FORM CHAMPUS 606

  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 800 12,000 0 -11,200 0 0
Annual Time Burden (Hours) 264 3,000 0 -2,736 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
Yes

$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.
03/07/1985


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