Active Duty Dental Program Claim Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form United Concordia C Active Duty Dental Program Claim Form	Form and Instruction	New	Available
Supporting statement for ADDP Claim Form.doc	Supporting Statement A	Uploaded 2012-07-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
203005	Active Duty Dental Program Claim Form	Form and Instruction	New

ICR Details

OMB Control No: 0720-0053	ICR Reference No: 201207-0720-006
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Active Duty Dental Program Claim Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/06/2012
	Date Received in OIRA: 07/05/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2015	36 Months From Approved
Responses	177,000	0	0
Time Burden (Hours)	14,750	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This form will be used by private sector dental professionals that provide dental care to Active Duty Service Members under the Active Duty Dental Program (ADDP). Many of these Service Members are not located near a military dental clinic and receive their dental care in the private sector. The new form is needed to update the dental readiness of Service Members treated in this program so that they can maintain worldwide deployment status and reduces paperwork by combining the dental claim and dental readiness into one form.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 48232	09/22/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 25707	05/01/2012
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
Active Duty Dental Program Claim Form	United Concordia Claim Form	Active Duty Dental Program

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ICR Summary of Burden

table that charts list 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	177,000	0	0	177,000	0	0
Annual Time Burden (Hours)	14,750	0	0	14,750	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: New Collection

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Annual Cost to Federal Government:

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

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Common Form ICR:  No

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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

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