Family Member Travel Screening

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DD X678-4 TEST DD Form X678 Series	Form and Instruction	New	Available
SSN Letters X678 series.pdf	Supplementary Document	Uploaded 2016-10-06	Available
DoDI 1315.19 - Authorizing Special Needs Family Members Travel Overseas at Government Expense.pdf	Supplementary Document	Uploaded 2016-10-06	Available
FMTS Pilot Forms Supporting Statement A FINAL.doc	Supporting Statement A	Uploaded 2016-10-06	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
223831	DD Form X678 Series	Form and Instruction	New

ICR Details

OMB Control No: 0704-0560	ICR Reference No: 201610-0704-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOD/DODDEP	Agency Tracking No: 0704-AAJT
Title: Family Member Travel Screening
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/18/2016
	Date Received in OIRA: 10/12/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2019	36 Months From Approved
Responses	17,943	0	0
Time Burden (Hours)	4,617	0	0
Cost Burden (Dollars)	177,030	0	0

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Abstract: The FMTS forms are used during the DoD FMTS process when active duty Service members with Permanent Change of Station (PCS) orders request Command sponsorship for accompanied travel to remote or OCONUS installations. These forms document any special medical, dental, and/or educational needs of dependents to assist in determining the availability of care at a new installation.

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Authorizing Statute(s): None

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:
	81 FR 4266	01/26/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 69518	10/06/2016
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
DD Form X678 Series	DD X678-4 TEST, DD X678 TEST, DD X678-3 TEST, DD X678-1 TEST, DD X678-2 TEST	Administrative Review Checklist ,   Screening Verification ,   Medical and Educational Information ,   Dental Health Information ,   Patient Care Review

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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	17,943	0	0	17,943	0	0
Annual Time Burden (Hours)	4,617	0	0	4,617	0	0
Annual Cost Burden (Dollars)	177,030	0	0	177,030	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection with a new associated burden.

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Annual Cost to Federal Government: $24,235

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: 10/12/2016

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