Statement of Personal Injury - Possible Third Party Liability Champus

Forms and Documents

Document	Type	Status	Availability
Form DD Form 2527 Statement of Personal Injury - Possible Third Party Liability Champus	Form	Modified	Available
Supporting Statement 0720-0003.doc	Supporting Statement A	Uploaded 2012-07-05	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
5566	Statement of Personal Injury - Possible Third Party Liability Champus	Form	Modified

ICR Details

OMB Control No: 0720-0003	ICR Reference No: 201207-0720-002
Status: Historical Active	Previous ICR Reference No: 200708-0720-001
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Statement of Personal Injury - Possible Third Party Liability Champus
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/27/2012
	Date Received in OIRA: 07/05/2012
Terms of Clearance: Approved consistent with previous terms of clearance and the following terms of clearance: the DoD shall take care in future submissions to submit requests for extensions in a timely manner in order to avoid violating the Paperwork Reduction Act.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2015	36 Months From Approved
Responses	224,399	0	0
Time Burden (Hours)	56,100	0	0
Cost Burden (Dollars)	98,560	0	0

---

Abstract: The statement of Personal Injury - Possible Third Party Liability form is completed by CHAMPUS beneficiaries suffering from personal injuries and receiving medical care at Government expense. The information is necessary in the assertion of the Government's right to recovery under the Federal Medical Care Recovery Act. The data is used in the evaluation and processing of these claims.

---

Authorizing Statute(s): EO: EO 1060 Name/Subject of EO: null
   US Code: 42 USC 2651-2653 Name of Law: null
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 60416	09/30/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 25709	05/01/2012
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Statement of Personal Injury - Possible Third Party Liability Champus	DD Form 2527	Statement of Personal Injury - Possible Third Party Liability TRICARE Management Activity

---

ICR Summary of Burden

	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	224,399	0	0	0	91,399	133,000
Annual Time Burden (Hours)	56,100	0	0	0	22,850	33,250
Annual Cost Burden (Dollars)	98,560	0	0	0	44,030	54,530

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: Increase in number of respondents. Additionally, this collection was not extended in a timely manner and lapsed into violation.

---

Annual Cost to Federal Government: $6,650,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

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? Uncollected

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 07/05/2012

---