0704-aaud_ssa_9.11.2018

SUPPORTING STATEMENT – PART A

DD Form X768

Exceptional Family Member Program (EFMP) Family Needs Assessment (FNA)

A. JUSTIFICATION

1. Need for the Information Collection. Section 1781c of Title 10, U.S.C. requires the Office of Community Support for Military Families with Special Needs (OSN) to enhance and improve support for military families with special needs. In this effort, OSN and the four Services developed the DD Form X768 Exceptional Family Member Program (EFMP) Family Needs Assessment (FNA) as standard documentation to guide assessment of needs, service planning and case transfer processes for the Family Support component of the EFMP. The EFMP FNA assists EFMP Family Support staff in identifying the needs of families and developing plans of action. The Family Services Plan Addendum allows EFMP Family Support staff and families to track identified steps in addressing their needs and goals. The Inter-Services Transfer Summary (ISTS) Addendum facilitates the transfer of cases between sister-Service Family Support Offices when a family requests a warm hand-off to a gaining installation.

The EFMP FNA addresses current differences in assessment processes and inconsistent transfer of cases across the Services. With this standardized form, installation-level EFMP Family Support Offices can provide a family support experience that is consistent across the Services and maintains continuity of services when military families with special needs have Permanent Change of Station (PCS) orders to a joint base or sister-Service location.

2. Use of the Information. This form is used by EFMP Family Support staff in collaboration with families who request assistance in navigating resources and systems of support. The Form documents a family’s needs and provides a plan for them to gain access to support and resources in the community which meets those needs. The Family Services Plan Addendum provides a plan of action and a way to track the progress towards goals set by the family with the assistance of the EFMP Family Support staff. The ISTS Addendum summarizes case management activities at the current installation and helps with a warm hand-off prior to a family transferring to a gaining sister-Service installation. The DD Form X768 will be standardized across the four Services with the goal of facilitating a consistent Family Support experience for all military families.

Form respondents include EFMP Family Support staff who complete the form in conjunction with families who are requesting support services. The DD Form X768 is completed using information gathered during an in-person or telephonic interview conducted with service members and/or their dependents. The EFMP Family Support staff documents the information obtained during the discussion to complete the DD Form X768. Afterwards, the FNA is uploaded, stored, and maintained internally in their web-based secured database in accordance with their Service specific guidance. A family may request a copy of the Form.

3. Use of Information Technology. 0% of responses are collected electronically. The DD Form may be completed electronically as a PDF-fillable form or printed and completed by hand by the EFMP Family Support staff. The PDF-fillable version of the form is intended to reduce the burden on respondents when the form is transferred to additional offices.
   
   

4. Non-duplication. While demographic and some medical and educational information may be already available from various sources, there are no standardized forms that contain all required information to provide Family Support Services other than the DD Form X768. This form was developed based on leading practices and ground-level insight from the four Military Services. Each of the Services may collect and track Family Support information, but none do so in a way that is as standardized or comprehensive as the EFMP FNA.
   
   
   

5. Burden on Small Business. No staff outside of the Military Services will complete any portion of the FNA. There is no burden on small business.
   
   
   

6. Less Frequent Collection. These forms are intended to be completed on a voluntary basis once per PCS cycle, per family, as appropriate.

7. Paperwork Reduction Act Guidelines. There are no special circumstances. This collection will be conducted in a manner consistent with the guidelines contained in 5 CFR 1320.5(d)(2).
   
   

8. Consultation and Public Comments

Part A: PUBLIC NOTICE

A 60-Day Federal Register Notice (FRN) for the collection published on Friday, June 8, 2018. The 60-Day FRN citation is 83 FRN 26661.

1 comment was received during the 60-Day Comment Period. It is included below in the order they were received, as well as our Agency’s response to the comment.

“Please do not include question that require participants to list citizenship status or country of origen. [sic]”

We are not asking any questions about citizenship or country of origin.

A 30-Day Federal Register Notice for the collection published on Thursday, September 20, 2018. The 30-Day FRN citation is 83 FRN 47610.

Part B: CONSULTATION

OSN consulted with the four Military Services to develop the form and incorporate leading practices from each of the Services’ Family Support assessment forms. The use of the FNA will be monitored by the Office of Special Needs and the Services on a regular basis to ensure that the form is adjusted to reflect the evolving needs of the DoD, as appropriate.

9. Gifts or Payment. No payment or gift will be made to respondents.
   
   

10. Confidentiality. All data are protected by the Privacy Act of 1974 and are protected according to the regulations therein, and by related DoD directives and instructions. All forms include a Privacy Act Statement, which notify the public of their privacy rights.
    
    
    

The data on the forms is covered in several SORNS:

• Department of the Navy (Navy and Marine Corps), M01754-6, Exceptional Family Member Program Records: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570631/m01754-6/

• Department of the Army, A0608b CFSC, Personal Affairs; Army Community Service Assistance Files: https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570054/a0600-8-104-ahrc/

• Department of the Air Force, F036 AFPC Z, Air Force Family Integrated Results and Statistical Tracking (AFFIRST): https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/569813/f036-afpc-z/

• Department of the Navy (Navy and Marine Corps), N01754-4, Navy Family Accountability and Assessment System (NFAAS): https://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570335/n01754-4/

Privacy Impact Assessment (PIA): A PIA is not required because if the form is stored electronically, the installation EFMP Family Support Staff will follow their Service-specific guidance and procedures for storing PII into their respective, secured client records database.

Retention schedule available through the links provided for SORNs.

11. Sensitive Questions. This form is used to identify and navigate Family Support services for families with special medical and/or educational needs. It documents a family’s needs and provides a plan for the family to gain access to support and resources in the community which meets those needs.

Personal Identifying Information (PII): Respondents are advised that their data are for OFFICIAL USE ONLY and will be maintained and used in strict confidence and in accordance with Federal law and regulations. Procedures are in place to protect the confidentiality of the information. The paper forms will be secured to protect PII in accordance with DoD regulations.

Sensitive Questions (i.e., sexual behavior or attitudes, religious beliefs, race and/or ethnicity race and ethnicity): Not applicable.

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	Respondent Burden Hours
DD Form X768 FNA	20,000 Family Members*	1	20,000	30 minutes	10,000 hours

*NOTE: The DD Form X768 FNA is completed by Family Support staff; however, the family member(s) are included as “respondents” because they provide information and input during a 30-minute conversation with the Family Support staff to appropriately complete the form.

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 X768 FNA	20,000 Family Members*	30 minutes*	$27.17	$13.59	$271,800

*NOTE: The DD Form X768 FNA is completed by Family Support staff; however, the family member(s) are included as “respondents” because they provide information and input during a 30-minute conversation with the Family Support staff in order to appropriately complete the form.

The mean hourly wage for family members is according to the US Census Bureau 2015 Income and Poverty in the United States Current Population Reports.

13. Respondent Costs Other Than Burden Hour Costs. There are no other annualized costs to respondents other than the labor burden costs addressed in Item 12.
    
    

14. Cost to the Federal Government. Processing for the DD Form X768 FNA includes assembling and forwarding the form when a family requests a warm hand-off to a sister-Service Family Support Office. An estimated 10% of annual responses (2,000 forms) will include a warm hand-off to a sister-Service Family Support Office and require that a DoD employee assemble and process the form.

The hourly wage was calculated using the average position level for a Family Support staff member (GS-11).

Labor Cost to the Federal Government
Hourly Pay for Family Support Staff (GS-11)	$25.16 (Annual pay derived from hourly pay: $52,329; Source: Office of Personnel Management)
Number of Packages	2,000 (10% of annual responses (20,000 forms) will include a warm hand-off)
Package Assembly and Forward Time	10 minutes (.17 hours)
Total Package Assembly and Forward Cost	$8,554.40 (2,000 forms multiplied by $25.16 hourly pay multiplied by .17 hours (10 minutes) assembly and forward time)

Operational and Maintenance Costs
Equipment	Printing	Postage	Software Purchases	Licensing Costs	Other	Total
N/A*	$4,000**	N/A*	N/A*	N/A*	N/A*	$4,000

*NOTE: Processing of the forms uses existing resources and does not require postage.
**NOTE: Printing costs were estimated at $.05 per page. The DD Form X768 has 4 pages per form that are printed.

Total Cost to the Federal Government
Operational and Maintenance Costs	Labor Cost to the Federal Government	Total Cost (O&M Costs + Labor Cost)
$4,000	$8,554.40	$12,554.40

15. Reasons for Change in Burden. This is a new collection with a new associated burden.
    
    

16. Publication of Results. The results of the information collection will not be published as a DoD publication or for publication external to DoD.

17. Non-Display of OMB Expiration Date. The non-display of the expiration date of OMB approval on the collection instruction is not being requested.
    
    

18. Exceptions to "Certification for Paperwork Reduction Submissions". No exemptions to the provisions certified.

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