SUPPORTING STATEMENT
Exceptional Family Member Program
1. Need for Information Collection The Individuals with Disabilities Education Act, (Sections 1400 et seq. of title 20, United States Code) and the Defense Dependents Education Act, (Sections 921 et seq. of title 20, United States Code) require the Department of Defense (DoD) to provide early intervention services to developmentally delayed infants and toddlers (birth through 2) and special education and medically related services to children with disabilities from three through 21 years of age who are eligible to attend a DoD school. In order to ensure the availability of necessary medical and educational services for family members, the Department must identify those who have special health or educational needs. The needs are considered when approving family travel to an overseas location where DoD must provide the services. The Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Public Law 94-191) requires specific language to advise individuals that personally identifiable health information shall not be used or disclosed except for specifically permitted purposes, unless informed consent is provided by the individual. The Department is standardizing the information collection to ensure that appropriate information is collected and that it meets the data collection HIPAA requirements.
2. Use of Information
The purpose of this information collection is to identify medical and educational requirements of family members when family travel to an overseas assignment is being considered. Respondents are Military members and DoD civilian employees, private physicians and school personnel. This information collection is primarily used by the Uniformed Services to identify those individuals requiring special consideration when authorizing family travel to an overseas location. The DD Form 2792, “Exceptional Family Member Medical Summary,” (Atch 3) and DD Form 2792-1, “Exceptional Family Member Education Summary”, which are the forms associated with this information collection, provide appropriate information. The information is provided to both medical and educational screening committees in overseas locations for their determination of the availability of medical and educational resources necessary to meet the family member’s needs. The medical and/or educational recommendation is supplied to the appropriate Military Department's personnel department in determining a future assignment for the service member. This information collection may also be used to identify available medical and educational resources to DoD civilian employees who are considering a job overseas to assist them in deciding whether to relocate overseas with a family member who has special medical or educational needs. The information is not supplied to agencies outside of the Department of Defense. Respondents update the forms every three years.
3. The DD Form 2792 and DD Form 2792-1 are available to the public electronically on-line from the Department of Defense forms website (http://www.dtic.mil/whs/directives/infomgt/forms/formsprogram.htm). For respondents who have access to computerized information technology, the forms can be completed on-line before printing for signature. There are no current plans to submit the completed forms electronically due to the number of individuals who must sign the form (sponsor or family member, civilian physician and/or public school officials). Although the Department has electronically generated the form, the form includes confidential medical information that must be entered by a physician. It is not practical to require that this information be entered electronically.
4. Efforts to Identify Duplication Investigation resulted in no findings of duplicate records. The information collection is not available in any centralized location and requires the assistance of military personnel and DoD civilian employees in providing information. Each form contains unique and original information that pertains only to the medical or educational needs of one family member.
5. Methods Used to Minimize Burden on Small Entities The use of this form will not impact small businesses or other small entities.
6. Consequences of Not Collecting the Information If this information is not collected, it will be impossible for the Military Departments to consider the special medical and/or educational needs of family members when approving overseas travel, nor would it be possible to inform civilian employees of the availability of services overseas. If the information is collected less often, it may be inaccurate. This could result in an incorrect decision about assignment and thus a lack of adequate resources to meet the family member's medical and/or educational needs.
7. Special Circumstances There are no special circumstances. This collection will be conducted in a manner consistent with the guidelines contained in 5 CFR 1320.5(d)(2).
8. Agency 60-Day Federal Register Notice and Consultations Outside the Agency
An agency 60-Day Federal Notice was published in the Federal Register. No public comments were received in response to the notice.
9. Payments to Respondents No payment or gift will be made to respondents.
10. Assurance of Confidentiality
All data are protected by the Privacy Act of 1974 and are protected according to the regulations therein, and by related DoD directives and instructions.
Sensitive Questions
All of the information on DD Form 2792 and DD Form 2792-1 is considered sensitive. The forms collect information about family members and their medical or educational disabilities. The purpose of the forms, however, requires that such information be collected so that the medical and educational needs can be met overseas.
12. Estimates of Annual Response Burden and Labor Cost for Hour Burden to the Respondent for Collection of Information.
a. Response Burden:
DD Form 2792, “EFM Medical Summary” (Those completed by civilian physicians)
Total annual respondents: 16,851
Frequency of response: 1
Total annual responses: 16,851
Burden per response: 30 minutes
Total burden hours: 8,426 hours
DD Form 2792-1, “EFM Educational Summary”
Total annual respondents: 26,481
Frequency of response: 1
Total annual responses: 26,481
Burden per response: 25 minutes
Total burden hours: 11,034 hours
Estimated Average Annual Burden
# Respondents: 43,332
# Responses per respondent 1
Total annual responses: 43,332
Average hours per response: .4491 (Total hours (8,426 + 11,034 = 19,460) divided by total responses (43,332))
Total annual burden : 19,460 (Total responses (43,332) x
average hrs per response (.4491))
Explanation of How Burden was Estimated.
The estimates below were based on numbers provided by the Service EFMP program managers and the calculations validated with them.
Labor Cost to Respondent.
DD Form 2792, “EFM Medical Summary”
Completing form 16,851 forms @ .25 (15 mins) per form = $410,960
Hourly pay for a clerk $15.18/hr @ $31,574 year
Copying, filing 16,851 X .25 (15 mins) per form = $ 68,291
DD Form 2792-1, “EFM Educational Summary”
Completing form 26,481 forms @ .08 (5 mins) per form = $ 72,346
Hourly pay for a clerk $15.33/hr @ $25,300 year
Copying, filing form 26,481 form @ .33 (20 mins) per form = $133,965
(3) Total Costs = $659,464
13. Estimates of Other Cost Burden for the Respondent for Collection of Information.
a. Total Capital and Start-up Cost. There are no start-up costs associated with this information collection. Respondents maintain the information for reasons other than to provide or keep records for the government.
Operation and Maintenance Cost.
Total Annual O&M Cost: $13,241
14. Estimates of Cost to the Federal Government.
GS-5/Step 4, Personnel Admin, hourly rate $15.66
$.26 X 30 mins = $7.80
Cost for 43,332 forms X $7.80= $337,990
$.26 X 10 mins = $2.60
Cost for 43,332 forms X $2.60 = $112,663
Cost to Print DD 2792
17,995 forms X $.13 per page X 6 pages = $13,144
Total cost for printing = $ 16,587
Total Cost to Government = $467,240
15. Changes in Burden. The is an extension of a previously approved collection.
16. Publication Plans/Time Schedule. The results of collection of this information will not be published for statistical use.
17. Approval Not to Display Expiration Date. Approval not to display the expiration date is not being sought.
18. Exceptions to the Certification Statement. No exceptions to the certification statement are being sought.
Statistical methods are not employed for collection of this information.
| File Type | application/msword |
| File Title | The following are the headings for each question to be used in the Supporting Statement: |
| Author | OUSD PR |
| Last Modified By | pltoppings |
| File Modified | 2011-01-31 |
| File Created | 2006-08-09 |