SUPPORTING STATEMENT FOR PAPERWORK REDUCTION ACT SUBMISSION
Statement of Personal Injury – Possible Third Party Liability (DD Form 2527).
1. Need for the Information Collection
The Federal Medical Care Recovery Act, 42 U.S.C. 2651-2653 provides for recovery of the reasonable value of medical care provided by the United States to a person who is injured or suffers a disease under circumstances creating tort liability in some third person. DD Form 2527 is required for investigating and asserting claims in favor of the United States arising out of such incidents.
When a claim for TRICARE benefits is identified as involving possible third party liability and the information is not submitted with the claim the TRICARE contractors request that the injured party (or a designee) complete DD Form 2527. To protect the interests of the Government the contractor suspends claims processing until the requested third party liability information is received. The contractor conducts a preliminary evaluation based upon the collection of information and refers the case to a designated appropriate legal officer of the Uniformed Services. The responsible Uniformed Services legal officer uses the information as a basis for asserting and settling the Government’s claim. When appropriate the information is forwarded to the Department of Justice as the basis for litigation.
2. Use of the Information
Section 1 of the Form is used to collect general information, such as name, address and telephone numbers about the military sponsor and the injured beneficiary and the date, time and location where the injury occurred.
Section 2 of the Form is used to collect information about motor vehicle accidents. Most of the investigations for possible third party liability involve motor vehicle accidents. Information about insurance coverage of the parties and whether the accident was work related is collected. Section 2 of the Form is also used to collect information about accidents that do not involve motor vehicles. Information such as the type of accident, the place where the injury occurred, the name of the property owner where the injury occurred and the cause of the injury is collected. The name and address of the employer is collected when the injury was work related.
Section 3 of the Form is used to collect miscellaneous information such as possible medical treatment at a Government hospital, the name and address of the beneficiary’s attorney, and information regarding any possible releases or settlements with another party to the accident. It also contains the certification, date and signature of the beneficiary (or a designee).
3. Use of Information Technology
There are currently no information technology techniques available as alternatives to reduce the burden. This form is used to collect specific factual information unique to individual beneficiaries.
There is a fillable
pdf form on the DoD forms Web site at
:
http://www.dtic.mil/whs/directives/infomgt/forms/formsprogram.htm
4. Non-duplication
Duplicate information may be available in the form of police reports, and the form allows substitution of the police report for information duplicated on the form.
No small business or other small entities are involved in this collection of information.
6. Less Frequent Collection
The collection can be conducted no less frequently than once, upon occurrence of the accidental injury.
7. Paperwork Reduction Act Guidelines
There are no special circumstances that require the collection to be conducted in a manner consistent with the guidelines in 5 CFR 1320.5(d)(2).
8. Consultation and Public Comments
The 60 Day Federal Register Notice for this collection of information was published on April 23, 2015; 80 FRN 22719. No public comments were received on this collection. The 30 Day Federal Register Notice for this information collection published on October 30, 2015; 80 FRN 66883.
No payments or gifts will be provided respondents other than the initial remuneration of claims by contractors.
10. Confidentiality
There is no specific statement of assurance of confidentiality. However, the form contains the necessary Privacy Act disclosures and statements.
Information will be kept private to the extent permitted by law and will be protected as described in the system of records notice. The applicable System of Record Notice (SORN) is EDTMA 04, Medical/Dental Claim History Files, located at:
A Privacy Impact Assessment (PIA) is not required. PIAs are not required for private sector care contractors.
11. Sensitive Questions
The Social Security Number (SSN) is needed for identification/tracking purposes. To date the Department has made no decisions on the use of another unique identifier.
DD Form 2527 collects data, including the SSN, on beneficiaries who suffer personal injuries that may result in third party liability (TPL) in favor of the US Government. At the present time, the SSN is the primary personal identifier used to identify the beneficiary's medical and claims records in Military Health System (MHS) databases and records systems. Upgrades to, or replacement of, MHS legacy systems databases to replace an individual's SSN with the individual's internal Electronic Data Interchange/Personal Number (EDIIPN) for use in internal DoD/MHS business processes will not eliminate the need to collect an individual's SSN through DD Form 2527
12. Respondent Burden, and its Labor Costs
a. Estimation of Respondent Burden
Burden estimate (hour)
The total hour burden for the respondents of 47,023 hours is based on an annual projected use of 188,090. The burden is based on an estimate of 15 minutes to complete the form. The annual burden hours calculated as follows:
Respondents: 188,090
Response time: 0.25 hours
Response Frequency: (on occasion)
Burden Hours: 47,023
b. Labor Cost of Respondent Burden
The labor cost of Respondents burden is estimated to be $400,632. This estimation is attained from using an average median (i.e. $8.50) of the national minimum wage rate. http://www.dol.gov/whd/minwage/america.htm.
The calculation used to derive the estimated Respondent burden of $400,632 is as follows:
Step 1.
$8.50 (min wage per hour) x .25 hours (represents 15mins of 60 mins) = $2.13 (represents the cost of 1 Respondent to fill out form)
Step 2
188,090 (respondents) x $2.13 (avg. response time cost) = $400,632 (total labor costs of respondents burden)
13. Respondent Costs Other Than Burden Hour Costs
The maximum annualized cost to respondents is estimated at $86,521 based upon postage costs for 188,090 respondents.
14. Cost to the Federal Government
Costs to the Federal Government are indirect as the form is processed by government contractors. This indirect cost is estimated to be $3,105,366.00 at $16.51 per form processed. This cost is offset by the millions of dollars collected by the uniformed services under the Federal Medical Case Recovery Act.
15. Reasons for Change in Burden
Fewer claim forms have been submitted since the previous OMB approval.
16. Publication of Results
There are no plans to publish or tabulate the information collected.
17. Non-Display of OMB Expiration Date
Approval is not sought for avoiding display of the expiration date.
18. Exceptions to "Certification for Paperwork Reduction Submissions"
There are no exceptions to the certification statement in Item 19, “Certification for
Paperwork reduction Act Submission,” of OMB Form 83-1.
| File Type | application/msword |
| File Title | SUPPORTING STATEMENT FOR PAPERWORK REDUCTION ACT SUBMISSION |
| Author | OCHAMPUS |
| Last Modified By | Caitlyn Borghi |
| File Modified | 2015-10-30 |
| File Created | 2015-10-06 |