TRICARE Select

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DD Form 3043 TRICARE Select Enrollment, Disenrollment, and Change Form	Form and Instruction	New	Available
TRICARE Select_OMB Supporting Statement Part A_Final - 12.08.2017.docx	Supporting Statement A	Uploaded 2017-12-08	Available
SSN Justification for TRICARE Select Enrollment_Disenrollment_Change Form.pdf	Supplementary Document	Uploaded 2017-12-08	Available
Memo to OIRA - TRICARE Select.pdf	Supplementary Document	Uploaded 2017-12-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
229387	TRICARE Select Enrollment, Disenrollment, and Change Form	Form and Instruction	New

ICR Details

OMB Control No: 0720-0061	ICR Reference No: 201712-0720-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: DOD/DODOASHA	Agency Tracking No: 0720-AAHG
Title: TRICARE Select
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 12/22/2017
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/22/2017
	Date Received in OIRA: 12/08/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2018	6 Months From Approved
Responses	99,300	0	0
Time Burden (Hours)	24,825	0	0
Cost Burden (Dollars)	179,733	0	0

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Abstract: The information collection is necessary to obtain non-active duty TRICARE beneficiary’s personal information needed to: (1) complete his/her enrollment into the “new” TRICARE Select health plan option as created by the National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2017, (2) dis-enroll a beneficiary, or (3) change the beneficiary’s enrollment (e.g., address, add a dependent, report other health insurance. This information is required to ensure the beneficiary’s benefits and claims are administered based on their plan of choice.

Emergency Justfication: Complying with the normal clearance procedures is likely to delay or disrupt the collection of information, and could have a negative impact on our service members, and compliance with new statute requirements, effective as of January 1, 2018. The National Defense Authorization Act for FY 2017 has mandated that two key aspects of the TRICARE system, TRICARE Extra and TRICARE Standard, which will be terminated as of December 31, 2017, are to be replaced by TRICARE Select. This information collection is necessary to obtain non-active duty TRICARE beneficiary’s personal information needed to complete his/her enrollment into the “new” TRICARE Select health plan option as created by the National Defense Authorization Act (NDAA) for Fiscal Year (FY) 2017, dis-enroll a beneficiary, or change the beneficiary’s enrollment. This information is required to ensure the beneficiary’s benefits and claims are administered based on their plan of choice. The information collection is essential to the mission of the Department.

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Authorizing Statute(s): PL: Pub.L. 114 - 328 701, 706, 715, 718, and 729 Name of Law: National Defense Authorization Act for FY 2017
  

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
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 57962	12/08/2017
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 Select Enrollment, Disenrollment, and Change Form	DD Form 3043	TRICARE Select Enrollment, Disenrollment, and Change Form

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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	99,300	0	0	99,300	0	0
Annual Time Burden (Hours)	24,825	0	0	24,825	0	0
Annual Cost Burden (Dollars)	179,733	0	0	179,733	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: $179,891

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

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: 12/08/2017

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