TRICARE Young Adult Application

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
0720-0049_SSA 12.30.2021.docx	Supporting Statement A	Uploaded 2021-12-30	Repair queued
TYA SSN Justification Memo PCLO Signature RK.pdf	Supplementary Document	Uploaded 2021-12-28	Missing upstream

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
197033	TRICARE Young Adult Application	Instruction	Modified

ICR Details

OMB Control No: 0720-0049	ICR Reference No: 202110-0720-002
Status: Received in OIRA	Previous ICR Reference No: 201809-0720-001
Agency/Subagency: DOD/DODOASHA	Agency Tracking No: 0720-0049
Title: TRICARE Young Adult Application
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 12/30/2021

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	12/31/2021
Responses	2,709	2,709
Time Burden (Hours)	677	677
Cost Burden (Dollars)	4,903	4,903

---

Abstract: The Ike Skelton National Defense Authorization Act for Fiscal Year 2011 (FY11), Section 702, aligns TRICARE Program eligibility by providing a means to extend the age of eligibility of TRICARE dependents from age 21 or 23 up to age 26 to allow the purchase of extended dependent medical coverage across existing TRICARE program options (Standard, Extra, and Prime). This is consistent with the intent of the Patient Protection and Affordable Care Act, the implementing Health and Human Services regulations, and the limitations of Chapter 55 of Title 10. Information gathered through this collection will be used by the regional managed care support contractors to process the applications to start, change, or terminate TRICARE Young Adult coverage.

---

Authorizing Statute(s): PL: Pub.L. 111 - 383 702 Name of Law: Ike Skelton National Defense Authorization Act for FY11
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 58898	10/25/2021
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 72584	12/22/2021
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
TRICARE Young Adult Application	DD-2947-2, DD-2947-3, DD-2947-1	TRICARE Young Adult Application ,   TRICARE Young Adult Application ,   TRICARE Young Adult Application

---

ICR Summary of Burden

table that charts list of burden

	Total Request	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	2,709	2,709	0	0	0	0
Annual Time Burden (Hours)	677	677	0	0	0	0
Annual Cost Burden (Dollars)	4,903	4,903	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:

---

Annual Cost to Federal Government: $15,617

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? No

---

Common Form ICR:  No

---

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: 12/30/2021

---