Information Collection

Statement of Personal Injury - Possible Third Party Liability Champus

IC 5566 under ICR 201510-0720-002 · OMB 0720-0003.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0003 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DD Form 2527, 2015 Statement of Personal Injury - Possible Third Party Liability Champus	Form
DD Form 2527, 2015 Statement of Personal Injury - Possible Third Party Liab dd2527_20150911.PDF www.dtic.mil/whs/directives/infomgt/forms/formsprogram.htm	Form

IC Title:

Statement of Personal Injury - Possible Third Party Liability Champus

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 28 CFR 43

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DD Form 2527, 20150911	Statement of Personal Injury - Possible Third Party Liability	dd2527_20150911.PDF	http://www.dtic.mil/whs/directives/infomgt/forms/formsprogram.htm	Yes	No	Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title: Medical/Dental Claim History Files

FR Citation: 78 FR 69076

Number of Respondents: 188,090

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	188,090	-36,309	224,399
Annual IC Time Burden (Hours)	47,023	-9,077	56,100
Annual IC Cost Burden (Dollars)	400,632	302,072	98,560

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.