Information Collection

DD Form 3040-3 - Patient Care Review

IC 236072 under ICR 201905-0704-001 · OMB 0704-0560.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0704-0560 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DD Form 3040-3 DD Form 3040-3 - Patient Care Review	Form and Instruction
DD Form 3040-3 Patient Care Review dd3040-3 draft 20190430.pdf	Form and Instruction

IC Title:

DD Form 3040-3 - Patient Care Review

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

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 3040-3	Patient Care Review	dd3040-3 draft 20190430.pdf		Yes	No	Fillable Printable

Line of Business: Defense and National Security

Subfunction: Operational Defense

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 46,147

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	46,147	46,147
Annual IC Time Burden (Hours)	11,537	11,537
Annual IC Cost Burden (Dollars)	1,115,373	1,115,373

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.