Family Member Travel Screening

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form DD Form 3040-3 Patient Care Review	Form and Instruction	Unchanged	Repair queued
Form DD Form 3040-3 DD Form 3040-3 - Patient Care Review	Form and Instruction	Unchanged	Repair queued
Form DD Form 3040-2 Dental Health Information	Form and Instruction	Unchanged	Repair queued
Form DD Form 3040-2 DD Form 3040-2 - Dental Health Information	Form and Instruction	Unchanged	Repair queued
Form DD Form 3040-1 Medical and Educational Information	Form and Instruction	Unchanged	Available
Form DD Form 3040-1 DD Form 3040-1 Medical and Educational Information	Form and Instruction	Unchanged	Repair queued
Form DD Form 3040 Screening Verification	Form and Instruction	Unchanged	Available
Form DD Form 3040 DD Form 3040 - Screening Verification	Form and Instruction	Unchanged	Repair queued
0704-0560_SSA_6.22.22.docx	Supporting Statement A	Uploaded 2022-06-21	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
236072	DD Form 3040-3 - Patient Care Review	Form and Instruction	Unchanged	Patient Care Review
236072	DD Form 3040-3 - Patient Care Review	Form and Instruction	Unchanged
236071	DD Form 3040-2 - Dental Health Information	Form and Instruction	Unchanged	Dental Health Information
236071	DD Form 3040-2 - Dental Health Information	Form and Instruction	Unchanged
236070	DD Form 3040-1 Medical and Educational Information	Form and Instruction	Unchanged	Medical and Educational Information
236070	DD Form 3040-1 Medical and Educational Information	Form and Instruction	Unchanged
223831	DD Form 3040 - Screening Verification	Form and Instruction	Unchanged	Screening Verification
223831	DD Form 3040 - Screening Verification	Form and Instruction	Unchanged

ICR Details

OMB Control No: 0704-0560	ICR Reference No: 202203-0704-004
Status: Historical Active	Previous ICR Reference No: 201905-0704-001
Agency/Subagency: DOW/DODDEP	Agency Tracking No:
Title: Family Member Travel Screening
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: 09/06/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/28/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2023	36 Months From Approved	09/30/2022
Responses	267,032	0	267,032
Time Burden (Hours)	84,931	0	84,931
Cost Burden (Dollars)	3,604,866	0	3,604,866

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Abstract: The FMTS forms are used during the DoD FMTS process when active duty Service members with Permanent Change of Station (PCS) orders request Command sponsorship for accompanied travel to remote or OCONUS installations. These forms document any special medical, dental, and/or educational needs of dependents to assist in determining the availability of care at a new installation.

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Authorizing Statute(s): US Code: 10 USC 136 Name of Law: Under Secretary of Defense for Personnel and Readiness
  

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:
	87 FR 15967	03/21/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 36832	06/21/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
DD Form 3040 - Screening Verification	DD Form 3040	Screening Verification
DD Form 3040-1 Medical and Educational Information	DD Form 3040-1	Medical and Educational Information
DD Form 3040-2 - Dental Health Information	DD Form 3040-2	Dental Health Information
DD Form 3040-3 - Patient Care Review	DD Form 3040-3	Patient Care Review

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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	267,032	267,032	0	0	0	0
Annual Time Burden (Hours)	84,931	84,931	0	0	0	0
Annual Cost Burden (Dollars)	3,604,866	3,604,866	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: $1,396,577

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

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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: 06/28/2022

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