TRICARE Select Enrollment, Disenrollment, and Change Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DD-3043 TRICARE Select Enrollment, Disenrollment, and Change Form	Form and Instruction	Modified	Available
TRICARE Select_OMB Supporting Statement Part A.docx	Supporting Statement A	Uploaded 2018-06-21	Available
SSN Justification for TRICARE Select Enrollment_Disenrollment_Change Form.pdf	Supplementary Document	Uploaded 2018-06-20	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	Modified

ICR Details

OMB Control No: 0720-0061	ICR Reference No: 201806-0720-001
Status: Active	Previous ICR Reference No: 201712-0720-001
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: TRICARE Select Enrollment, Disenrollment, and Change Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/24/2018
	Date Received in OIRA: 06/21/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2021	36 Months From Approved	08/31/2018
Responses	99,300	0	99,300
Time Burden (Hours)	24,825	0	24,825
Cost Burden (Dollars)	179,733	0	179,733

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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.

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Authorizing Statute(s): PL: Pub.L. 114 - 328 701 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
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 673	01/05/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 28840	06/21/2018
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-3043, DD-3043, DD-3043, DD-3043	TRICARE Select Enrollment, Disenrollment, and Change Form ,   TRICARE Select Enrollment, Disenrollment, and Change Form ,   TRICARE Select Enrollment, Disenrollment, and Change Form ,   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	99,300	0	0	0	0
Annual Time Burden (Hours)	24,825	24,825	0	0	0	0
Annual Cost Burden (Dollars)	179,733	179,733	0	0	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: No

Burden Reduction Due to:

Short Statement:

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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: 06/21/2018

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