Information Collection

TRICARE Select Enrollment, Disenrollment, and Change Form

IC 229387 under ICR 201712-0720-001 · OMB 0720-0061.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0720-0061 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DD Form 3043 TRICARE Select Enrollment, Disenrollment, and Change Form	Form and Instruction
DD Form 3043 TRICARE Select Enrollment, Disenrollment, and Change For DD3043 Final 20171208.pdf	Form and Instruction

IC Title:

TRICARE Select Enrollment, Disenrollment, and Change Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

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 and Instruction	DD Form 3043	TRICARE Select Enrollment, Disenrollment, and Change Form	DD3043 Final 20171208.pdf		Yes	No	Printable Only

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title: EDHA07 - Military Health Information System

FR Citation: 78 FR 69076

Number of Respondents: 99,300

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 75 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	99,300	99,300
Annual IC Time Burden (Hours)	24,825	24,825
Annual IC Cost Burden (Dollars)	179,733	179,733

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.