STATEMENT OF PERSONAL INJURY - POSSIBLE THIRD PARTY LIABILITY - CHAMPUS/CHAMPVA

ICR 198809-0704-007

OMB: 0704-0090

Federal Form Document

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Document
Name
Status
No forms / supporting documents in this ICR. Check IC Document Collections.
IC Document Collections
ICR Details
0704-0090 198809-0704-007
Historical Active 198805-0704-002
DOD/DODDEP
STATEMENT OF PERSONAL INJURY - POSSIBLE THIRD PARTY LIABILITY - CHAMPUS/CHAMPVA
No material or nonsubstantive change to a currently approved collection   No
Emergency 09/30/1988
Approved with change 09/30/1988
Retrieve Notice of Action (NOA) 09/30/1988
  Inventory as of this Action Requested Previously Approved
03/31/1991 03/31/1991 03/31/1991
30,000 0 30,000
17,000 0 17,000
0 0 0

THE STATE OF PERSONAL INJURY POSSIBLE THIRD PAR LIABILITY FORM IS COMPLETED BY CHAMPUS/CHAMPVA BENEFICIARIES SUFFERING FROM PERSONAL INJURIES AND RECEIVING MEDICAL CARE AT GOVERNMENT EXPENS THE INFORMATION IS NECESSARY IN THE ASSERTION OF THE GOVERNMENT'S RIGH TO RECOVERY UNDER THE FEDERAL MEDICAL CARE RECOVERY ACT. THE DATA IS USED IN THE EVALUATING AND PROCESSING OF CLAIMS.

None
None


No

1
IC Title Form No. Form Name
STATEMENT OF PERSONAL INJURY - POSSIBLE THIRD PARTY LIABILITY - CHAMPUS/CHAMPVA DD FORM 2527

  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 30,000 30,000 0 0 0 0
Annual Time Burden (Hours) 17,000 17,000 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
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.
09/30/1988


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