SSPA for 0720-0022 PASSBACK CHANGES ACCEPTED

SUPPORTING STATEMENT – PART A

DoD Active Duty/Reserve Forces Dental Examination – 0720-0022

A.  JUSTIFICATION

1.  Need for the Information Collection

This form is used by members of the Active and Reserve Components of the Armed Forces and certain DoD civilians to enable civilian dentists to document and report their dental health status. It is very difficult for Reserve component members to receive their routine dental care from active duty dentists, but they are required to document the fact that they have undergone an annual dental examination. Therefore, this form is used as a method for civilian dentists to confirm that an exam was completed and convey the dental health status of members of the Reserve Components and active duty members in remote locations to the Department of Defense. Authority is found in 10 U.S.C. Section 10206, Armed Forces Members: Physical Examinations, which states that each member of the Selected Reserve who is not on active duty shall have a comprehensive dental assessment on an annual basis.

2.  Use of the Information

The collection of this information is required to verify the health status of members of the Reserve Components, active duty members in remote locations and DoD civilians who deploy by the Department of Defense. Each Service disseminates this collection instrument electronically to respondents; respondents return the correctly filled out collection instrument—the DD Form 2813—electronically. Those respondents who do not have capability for electronic transfer of data, will return the DD Form 2813 to the service members or Service component records department to include in the corresponding records until it is possible to electronic scan the form to the electronic health record. The situation may include service members who are forward deployed or on ships without immediate electronic means to transfer the data. At the soonest availability, the appropriate Service component will upload the form into the Service specific information system.

When members of the Active or Reserve Components receive their annual examinations from civilian dentists, the dentists record the dental health status on the DD Form 2813 according to dental health status definitions on the form. The dentist notes whether the individual has any conditions that are expected to require treatment within the next 12 months, as well as the dentist's name, contact information, and signature/license number. Members return the form to their parent military organization, and their dental health status is entered into an electronic database, which tracks the deployments readiness of the members.

Once completed, information from the form is uploaded into Army, Navy, and Air Force specific information systems, as well as the DoD wide Defense Medical Surveillance System (DMSS). Military members must maintain an acceptable level of dental health because dental emergencies in military operations place an undue strain on the health care and medical evacuation systems in the area of military operations.

Since DD Form 2813 is used to collect personally identifiable information directly from individuals into a system of records, a Privacy Act Statement (PAS) is necessary. The PAS is provided in a conspicuous manner, at or before the point that PII is collected, regardless of the medium used for collection. A PAS on a paper or electronic form is generally placed at the beginning of the form, immediately following the title, before the first official heading/section, or immediately prior to where PII is collected. Per the DHA Privacy Office recommendation, the PAS will be at retained at the same location as the PAS currently on DD Form 2813.

3.  Use of Information Technology

The DD Form 2813 is available in several electronic formats to include PDF (Portable Document Format). Civilian dentists can access the form and submit it electronically to the member’s unit, although most are completing the form as part of the exam. Approximately 70% of responses are collected electronically. Less and less respondents hand-carry the DD Form 2813, as they rely more heavily on electronic means. Service Members are encouraged to use electronic means.

4.  Non-duplication

Personnel dental health status is unique data that is not tracked in other data collection systems.

5.  Burden on Small Business

This information collection does not have a significant economic impact on small businesses or entities.

6.  Less Frequent Collection

A member’s dental health status can quickly deteriorate to an unacceptable level and must be evaluated annually. An annual dental evaluation is a readiness requirement.

7.  Paperwork Reduction Act Guidelines

There are no special circumstances that require the collection to be conducted in a manner inconsistent with the guidelines delineated in 5 CFR 1320.5(d)(2). This collection of information is consistent with the guidelines in 5 CFR 1320.5(d)(2).

8.  Consultation and Public Comments

Part A: PUBLIC NOTICE

The 60-day Federal Register Notice for this information collection published on April 20, 2016; 81 FR 23278-23279. No comments were received.

The 30-day Federal Register Notice for this information collection published on August 30, 2016; 81 FR 59611-59612.

Part B: CONSULTATION

This collected instrument does not have applicability outside of the intended respondents. Feedback is solicited from representatives from the Air Force, Navy, and Army. The DD form 2813 is reviewed at least every three years or when policies or processes are changed that would impact the Form.

9.  Gifts or Payment

No payment or gift will be provided to the respondents. Individual dentists will decide if they require an additional fee for completing the form, or whether they will factor it into their cost of doing business. For active duty members who receive their care from civilian dentists through the Active Duty Dental Program, there is no fee associated with completion of this form.

10.  Confidentiality

The form will be filed in each service member’s dental record, which contains a Privacy Act Statement. Since DD Form 2813 is used to collect personally identifiable information directly from individuals into a system of records, a Privacy Act Statement (PAS) is necessary. The PAS is provided in a conspicuous manner, at or before the point that PII is collected, regardless of the medium used for collection. A PAS on a paper or electronic form is generally placed at the beginning of the form, immediately following the title, before the first official heading/section, or immediately prior to where PII is collected. Per the DHA Privacy Office recommendation, the PAS will be at retained at the same location as the PAS currently on the front of the DD Form 2813.

The applicable SORN(s) are listed below along with links to the full text.

Army: A0040-66b DASG, Health Care and Medical Treatment Record System (April 04, 2003, 68 FR 16484), http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569974/a0040-66b-dasg/

The Records Retention and Disposition Schedule is as follows:

Military health/dental and procurement/separation x-ray records are permanent. Clinical (inpatient), outpatient, dental and consultation record files for military members are destroyed after 50-75 years.

All records (except the Military Health/Dental records) which are active while individual is on active duty, then retired with individual's Military Personnel Records Jacket and the procurement/separation x-ray records which are forwarded to the National Personnel Records Center on an accumulation basis) are retained in an active file while treatment is provided and subsequently held for a period of 1 to 5 years following treatment before being retired to the National Personnel Records Center. Subsidiary medical records, of a temporary nature, are normally not retained long beyond termination of treatment; however, supporting documents determined to have significant documentation value to patient care and treatment are incorporated into the appropriate permanent record file.

Until the National Archives and Records Administration approves the disposition of Psychological Assessment and Selection Case records, treat as permanent.

Navy: N06150-2, Health Care Record System (June 16, 2003, 68 FR 35657), http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570394/n06150-2/

The Records Retention and Disposition Schedule is as follows:

Health care records are retained, retired, and disposed of in accordance with Secretary of the Navy Instruction 5215.5 (Disposal of Navy Marine Corps Records) and Bureau of Medicine and Surgery Instruction 6150.1 (Health Care Treatment Records).

Specifics are given below

Military health (medical and dental) records, are transferred with the member upon permanent change of duty station to his/her new duty station. These records are retired to the National Personnel Records Center, (Military Personnel Records), 9700 Page Avenue, St. Louis, MO 63132-5100; Naval Reserve Personnel Center, 4400 Dauphine Street, New Orleans, LA 70149-7800; and, Marine Corps Reserve Support Center, 10950 El Monte, Overland Park, KS 66211-1408.

Inpatient health records are transferred to the National Personnel Records Center, (Military Personnel Records), 9700 Page Avenue, St. Louis, MO 63132-5100 or to the National Personnel Records Center, (Civilian Personnel Records), 111 Winnebago Street, St. Louis, MO 63118-4199, two years after the calendar year of the last date of treatment.

Outpatient health records of civilians are transferred to the National Personnel Records Center, (Military Personnel Records), 9700 Page Avenue, St. Louis, MO 63132-5100 or to the National Personnel Records Center, (Civilian Personnel Records), 111 Winnebago Street, St. Louis, MO 63118-4199, two years after the calendar year of the last date of treatment.

X-ray files are retained on-site and destroyed three years after the last x-ray in the file. Asbestos x-rays are retained on site indefinitely.

Secondary health record may be retained separate from the health record. A notation is made in the health record that these records exist and where they are being kept. When the health record is retired or the patient transfers, these records should be entered in the health record.

Aviation medical records are retained at the activity and destroyed when 30 years old.

Marine Security Guard Battalion psychological examination, evaluation, and treatment case files containing medical records documenting fitness for assignment as Embassy Guards are retained at the activity and destroyed after 50 years.

Clinical psychology case files documenting suitability for special assignment will be retained at the originating medical treatment facility and destroyed when 50 years old.

Radiation exposure records for personnel are maintained indefinitely in the health record, and in a centralized exposure registry held by the Navy Environmental Health Center Detachment, Naval Dosimetry Center, Bethesda, MD 20889-5614.

Air Force: F044 AF SG E, Medical Record System (December 13, 2011, 76 FR 77498), http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569877/f044-f-sg-e/

The Records Retention and Disposition Schedule is as follows:

Files retention is based on medical need. The current limitation is ten years. After use is determined to be no longer required, electronic records are archived and then deleted from server for active use.

The applicable Privacy Impact Assessments (PIAs) are listed below: The PIAs can be accessed at the following URLs:

Army & Air Force: Corporate Dental System, http://armymedicine.mil/Documents/Corporate_Dental_System-CDS-Renewal.pdf

Navy: Dental Common Access System (DENCAS), http://www.doncio.navy.mil/uploads/Summary_BUMED_DENCAS_PIA_05_24_2013.pdf

& Dental Digital Imaging (DDI) System, http://www.doncio.navy.mil/uploads/Summary_BUMED_DDI_PIA_08-23-2012.pdf

11.  Sensitive Questions

The respondent’s Social Security Number is collected. A Social Security Number Justification Memo is provided separately.

12.  Respondent Burden, and its Labor Costs

a.  Estimation of Respondent Burden

Estimation of Respondent Burden Hours
	Number of Respondents	Number of Responses per Respondent	Number of Total Annual Responses	Response Time (Amount of time needed to complete the collection instrument)	Respondent Burden Hours (Total Annual Responses multiplied by Response Time) Please compute these into hours)
DD Form 2813	150,000	5	750,000	3 minutes	37,500
Total	150,000	5	750,000.	3 minutes	37,500

b.  Labor Cost of Respondent Burden

Labor Cost of Respondent Burden
	Number of Responses	Response Time per Response	Respondent Hourly Wage	Labor Burden per Response (Response Time multiplied by Respondent Hourly Wage)	Total Labor Burden (Number of Respondents multiplied by Response Time multiplied by Respondent Hourly Wage)
DD Form 2813	750,000	3 minutes	$82.86	$4.14	$621,450
Total	750.000	3 minutes	$82.86	$4.14	$621,450

The respondent hourly wage provided is according to the Bureau of Labor Statistics “Occupational Employment and Wages, May 2015.” The wage figure can be found at: http://www.bls.gov/oes/current/oes291021.htm”

13.  Respondent Costs Other Than Burden Hour Costs

There will be no additional cost burden to respondents.

14.  Cost to the Federal Government

The Federal Government will be recording one response, final DRC (Dental Readiness Class) based on the respondents evaluation. Utilizing Service personnel equivalent to administrative assistants, the hourly wage provided is according to the Bureau of Labor Statistics “Secretaries and Administrative Assistants, 2015” median pay. The wage figure can be found at: http://www.bls.gov/ooh/office-and-administrative-support/secretaries-and-administrative-assistants.htm

	Collection Instrument DD Form 2813	Total
Number of Responses	150,000	150,000
Processing Time Per Response (in hours)	0.0166 hours	0.0166 hours
Hourly Wage of Worker(s) Processing Responses	$17.55	$17.55
Cost to Process Each Response (Processing Time Per Response multiplied by Hourly Wage of Worker(s) Processing Responses)	$0.29	$0.29
Total Cost to Process Responses (Cost to Process Each Response multiplied by Number of Responses	43,500	$43,500

DoD government facilities have existing scanners, computers and other electronic equipment that is utilized for multiple functions. Hence the additional cost is negligible and no additional equipment is needed.

Operational and Maintenance Costs
Equipment	Printing	Postage	Software Purchases	Licensing Costs	Other	Total
0	0	0	0	0	0	0

Total Cost to the Federal Government
Operational and Maintenance Costs	Labor Cost to the Federal Government	Total Cost (O&M Costs + Labor Cost)
0	$43,500	$43,500

There will be a minimal cost to the government as the form is designed to be electronically distributed by the military organizations that use the form as necessary.

15.  Reasons for Change in Burden

There is a slight increase from previous 35,625 hours to 37,500 due to an estimated increase in remote service members. The number of respondents is not a static number, dependent on physical location of troops at the time and that is mission oriented.

16.  Publication of Results

There is no plan to publish or tabulate the information collected in an independent report. Data will be entered into an electronic database.

17.  Non-Display of OMB Expiration Date

Approval not to display the expiration date is not being sought.

18.  Exceptions to "Certification for Paperwork Reduction Submissions"

No exceptions to the certification statement are requested.

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