Statement of Personal Injury - Possible Third Party Liability Champus

Forms and Documents

Document	Type	Status	Availability
Form DD Form 2527, 2015 Statement of Personal Injury - Possible Third Party Liability Champus	Form	Modified	Repair queued
Supporting Statement 0720-0003 ICB comments_FINAL_06OCT2015.doc	Supporting Statement A	Uploaded 2015-10-30	Available
Signed SSN justification DD2527.PDF	Supplementary Document	Uploaded 2015-10-27	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: 201510-0720-002
Status: Historical Active	Previous ICR Reference No: 201207-0720-002
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Statement of Personal Injury - Possible Third Party Liability Champus
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/06/2016
	Date Received in OIRA: 10/30/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2019	36 Months From Approved
Responses	188,090	0	0
Time Burden (Hours)	47,023	0	0
Cost Burden (Dollars)	400,632	0	0

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Abstract: This information is completed by TRICARE beneficiaries suffering from personal injuries and receiving medical care at Government expense. This information is necessary in the assertion of the Government's right to recover under the Federal Medical Care Recovery Act. The data is used in the evaluation and processing of these claims.

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Authorizing Statute(s): US Code: 42 USC 2651-2653 Name of Law: The Federal Medical Care Recovery Act
  

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:
	80 FR 22719	04/23/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 66883	10/30/2015
Did the Agency receive public comments on this ICR? No

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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, 20150911	Statement of Personal Injury - Possible Third Party Liability

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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	188,090	0	0	0	-36,309	224,399
Annual Time Burden (Hours)	47,023	0	0	0	-9,077	56,100
Annual Cost Burden (Dollars)	400,632	0	0	0	302,072	98,560

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: Fewer claim forms have been submitted since the previous OMB approval.

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Annual Cost to Federal Government: $3,105,366

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: 10/30/2015

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