TRICARE Retiree Dental Program Enrollment Application

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Delta Dental Form TRICARE Retiree Dental Program Enrollment Appication	Form	Modified	Available
OMB Supporting Statement 0720-0015 PASSBACK SEP13_edits_gm17Nov2016-CLEAN.doc	Supporting Statement A	Uploaded 2016-11-28	Available
0720-0015 SSN MFR signed_151028(2).PDF	Supplementary Document	Uploaded 2016-04-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
5586	TRICARE Retiree Dental Program Enrollment Appication	Form	Modified

ICR Details

OMB Control No: 0720-0015	ICR Reference No: 201604-0720-004
Status: Historical Active	Previous ICR Reference No: 201207-0720-003
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: TRICARE Retiree Dental Program Enrollment Application
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 with change	Conclusion Date: 12/09/2016
	Date Received in OIRA: 04/29/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2019	36 Months From Approved
Responses	60,000	0	0
Time Burden (Hours)	15,000	0	0
Cost Burden (Dollars)	375,000	0	0

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Abstract: This information is completed by Uniformed Service members entitled to retired pay and their eligible family members who are seeking enrollment in the TRICARE Retiree Dental Program (TRDP). The information is necessary to enable the DoD-contracted third party administrator of the program to identify the program's applicants, determine their eligibility for TRDP enrollment, establish the premium payment amount, and verify by the applicant's signature that the applicant understands the benefits and rules of the program.

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Authorizing Statute(s): US Code: 10 USC 1076c Name of Law: null
  

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 35637	06/22/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 24069	04/25/2016
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
TRICARE Retiree Dental Program Enrollment Appication	Delta Dental Form	TRICARE Retiree Dental Program Enrollment Application

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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	60,000	0	0	-4,000	0	64,000
Annual Time Burden (Hours)	15,000	0	0	-1,000	0	16,000
Annual Cost Burden (Dollars)	375,000	0	0	375,000	0	0

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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This is a reinstatement of a previously approved collection for which OMB approval has expired. There is a decrease in burden due to a decrease in the number of responses.

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Annual Cost to Federal Government: $2,280

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: 04/29/2016

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