SUPPORTING STATEMENT - PART A
Family Member Travel Screening – OMB Control Number 0704-0560
1. Need for the Information Collection
The DD Forms 3040, 3040-1, 3040-2, and 3040-3 will be used during the Family Member Travel Screening (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 will document any special medical, dental, and/or educational needs of dependents accompanying the Service member to assist in determining the availability of care at a gaining installation.
These forms are required by the National Defense Authorization Act of 2010 (NDAA 2010), 10 USC 136 ‘Under Secretary of Defense for Personnel and Readiness,’ and the Department of Defense Instruction (DoDI) 1315.19, “The Exceptional Family Member Program (EFMP).” The NDAA 2010 established the Office of Special Needs (OSN) and tasked OSN with developing, implementing, and overseeing comprehensive policies surrounding assignment and support for these military families. Additionally, per DoDI 1315.19, military departments are required to screen family members of active duty Service members for special needs and to coordinate assignments for Service members enrolled in the Exceptional Family Member Program (EFMP) to verify if necessary medical and/or educational services are available at the next assignment for family members with special needs.
2. Use of the Information
These forms will be used by Service Personnel/Transferring Commands and the military medical departments in the family travel screening component of the Assignment Coordination process for families relocating to remote or locations outside the continental United States (OCONUS). They will document any travel concerns, which may include medical, dental, and/or educational needs, of dependents accompanying a Service member to assist in determining the availability of care at a gaining installation.
FMTS personnel will distribute the forms, via email, to active duty Service members with notification of an OCONUS assignment and specific remote locations.
DD Forms 3040 and 3040-1 may be completed by the Service member for their dependents. The DD Form 3040-2 will be required for all dependents over the age of 12 months, and completed by dental providers. The DD Form 3040-3 will be required for each dependent that receives care outside of a Military Treatment Facility and completed by a qualified civilian medical provider. Once the forms are completed, they will be submitted, in-person, to the FMTS office. An in-person appointment will be scheduled with the appointed FMTS medical screener, a qualified provider who will then complete the forms documenting any potential travel concerns, such as medical, dental, and/or educational needs.
3. Use of Information Technology
The forms are distributed as PDF-fillable forms and may be completed electronically then printed for completion and submission.
4. Non-duplication
The information obtained through this collection is unique and is not already available for use or adaptation from another cleared source.
5. Burden on Small Businesses
This information collection does not impose a significant economic impact on a substantial number of small businesses or entities.
Medical and dental providers outside of the Military Services may be small business respondents. These respondents may be required to complete the DD Form 3040-2 or DD Form 3040-3. These two one-page forms are simplified in an effort to reduce the burden on respondents and do not require respondents to conduct activities outside of their normal business operations.
6. Less Frequent Collection
Information is collected once for any OCONUS or remote PCS cycle for each dependent. If the information is not collected, there could be challenges determining the availability of care at installations. These challenges could result in the early return of dependents from their new duty location due to the unavailability of services and could negatively impact the military readiness of active duty Service members.
7. Paperwork Reduction Act Guidelines
This collection of information does not require collection to be conducted in a manner inconsistent with the guidelines delineated 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 Monday, March 21, 2022). The 60-Day FRN citation is 87 FRN 15967.
One comment was received during the 60-Day Comment Period. It is included below, as well as our Agency’s response to the comment.
Submitted comment:
“Exceptional Families of the Military is commenting to share that we have concerns that the request for public comment on the DD Forms 3040, 3040-1, 3040-2, and 3040-3 are impossible for the general public to comment on due to the fact that these forms are not available for viewing without the use of a Common Access Card. Access to these forms should have been provided prior to the comment period closing. Exceptional Families of the Military, therefore, respectfully ask for the comments to be re-open after closing with the forms open to the public to gain better feedback from not only the general public but also service members, military family members, and/or the caregiver of the EFMP family member.”
The Office of Special Needs Response:
Thank you for your comment. The DD Forms 3040, 3040-1, 3040-2, and 3040-3 have not yet been posted on The Official DoD Website for DoD Forms (https://www.esd.whs.mil/Directives/forms/mil), a public website, because the release/publication of these DD Forms is pending the completion and publication of DoD Policies regarding the family member travel screening process. Once the DoD Policies are published these DD Forms will be posted on the site above.
A 30-Day Federal Register Notice for the collection published on Tuesday, June 21, 2022. The 30-Day FRN citation is 87 FR 36832 FRN 36832-36833.
Part B: CONSULTATION
No additional consultation apart from soliciting public comments through the Federal Register was conducted for this submission.
9. Gifts or Payment
No payments or gifts are being offered to respondents as an incentive to participate in the collection.
10. Confidentiality
Privacy Act Statements are provided to all respondents on each of the forms.
The Systems of Record Notices for this collection may be found online at the following links:
Department of Defense (DoD)
DMDC 02 DoD: Defense Enrollment Eligibility Reporting Systems (DEERS)
EDHA 07: Military Health Information System
Department of Defense Education Activity (DoDEA)
DoDEA 26: DoDEA Educational Records
DoDEA 29: DoDEA Non-DoD Schools Program
A Privacy Impact Assessment (PIA) is not required for this collection because PII is not being collected electronically.
Retention schedules are as follows:
DMDC 02: Temporary. Cut off upon last episode of patient care or last entry to the patient record is annotated. Delete/Destroy when 75 years old.
EDHA 07: Permanent: Cut off (take a snapshot) at end of Fiscal Year and transfer to NARA in accordance with 36 CFR 1228.270 and 36 CFR 1234 Output records (electronic or paper summary reports) are deleted or destroyed when no longer needed for operational purposes.
DODEA 26: School Student Record Files:
Destroy/delete files, other than secondary transcripts, of all information except report cards or other records of academic promotion or retention data after 1 year. Destroy or delete all non-secondary transcript files 3-5 years after graduation, transfer, withdrawal, or death of student.
Attendance and Discipline Files:
Cut off at end of school year. Destroy/delete when one-year old.
Health Record Files:
Place in student record file upon transfer, withdrawal or death of student.
School Ancillary Service Files:
Transfer to student record file upon graduation, transfer, withdrawal or death of student.
School Mediation Agreement and Hearing Results Files:
Cut off after final decision. Destroy/delete when 20 years old.
School Special Education Files:
Cut off on graduation, transfer, withdrawal, or death of student. Destroy/delete when 5 years old.
Student Administrative Files:
Cut off at end of school year or upon year student transfers. Destroy after 1 year unless needed for further reference.
Student Record Request and Disclosure Files.
Cut off at end of school year. Destroy/delete when 2 years old.
Historical School Files:
Transcripts. Secondary Schools and Panama college transcripts will be cut off upon transfer, withdrawal, or death of student. Secondary transcript files are destroyed when 50 years old.
DODEA 29: Department of Defense Education Activity Non-DoD Schools Program
Documents and electronic records on enrollment and registration, school registration forms, parental correspondence, other notes and related information and similar records are destroyed five (5) years after transfer, withdrawal, or death of student.
Tutor record files are destroyed six (6) years and three (3) months after period covered by account.
Records of students not approved for the program are destroyed one year after end of school year.
11. Sensitive Questions
All of the information on the DD Forms 3040, 3040-1, 3040-2, and 3040-3 is considered sensitive. The purpose of the forms, however, requires that such information be collected so that the medical, dental and educational needs can be identified and coordinated with the overseas locations. Each form contains a Privacy Act Statement that explains to the respondent the necessity for collecting sensitive data.
12. Respondent Burden and its Labor Costs
Part A: ESTIMATION OF RESPONDENT BURDEN
[DD Form 3040 – Screening Verification]
Number of Respondents: 35,173
Number of Responses Per Respondent: 1
Number of Total Annual Responses: 35,173
Response Time: 10 minutes
Respondent Burden Hours: 5,862 hours
[DD Form 3040-1 – Medical and Educational Information]
Number of Respondents: 84,414
Number of Responses Per Respondent: 1
Number of Total Annual Responses: 84,414
Response Time: 30 minutes
Respondent Burden Hours: 42,207 hours
[DD Form 3040-2 – Dental Health Information]
Number of Respondents: 101,298
Number of Responses Per Respondent: 1
Number of Total Annual Responses: 101,298
Response Time: 15 minutes
Respondent Burden Hours: 25,324.5 hours
[DD Form 3040-3 – Patient Care Review]
Number of Respondents: 46,147
Number of Responses Per Respondent: 1
Number of Total Annual Responses: 46,147
Response Time: 15 minutes
Respondent Burden Hours: 11,536.75 hours
Total Submission Burden
Total Number of Respondents: 267,032
Total Number of Annual Responses: 267,032
Total Respondent Burden Hours: 84,930 hours
Part B: LABOR COST OF RESPONDENT BURDEN
[DD Form 3040 – Screening Verification]
Number of Total Annual Responses: 35,173
Response Time: 10 minutes
Respondent Hourly Wage: $7.25
Labor Burden per Response: $1.21
Total Labor Burden: $42,559.33
[DD Form 3040-1 – Medical and Educational Information]
Number of Total Annual Responses: 84,414
Response Time: 30 minutes
Respondent Hourly Wage: $7.25
Labor Burden per Response: $3.625
Total Labor Burden: $306,000.75
[DD Form 3040-2 – Dental Health Information]
Number of Total Annual Responses: 101,298
Response Time: 15 minutes
Respondent Hourly Wage: $84.54
Labor Burden per Response: $21.135
Total Labor Burden: $2,140,933.23
[DD Form 3040-3 – Patient Care Review]
Number of Total Annual Responses: 46,147
Response Time: 15 minutes
Respondent Hourly Wage: $96.68
Labor Burden per Response: $24.17
Total Labor Burden: $1,115,372.99
Overall Labor Burden
Total Number of Annual Responses: 267,032
Total Labor Burden: $3,604,866.3
The Respondent hourly wage was determined by using the Federal minimum wage of $7.25/hr and the hourly wages for Dentists and General Practitioners, as applicable. (https://www.bls.gov/oes/current/oes_nat.htm)
13. Respondent Costs Other Than Burden Hour Costs
There are no annualized costs to respondents other than the labor burden costs addressed in Section 12 of this document to complete this collection.
14. Cost to the Federal Government
Part A: LABOR COST TO THE FEDERAL GOVERNMENT
[DD Form 3040 –DD3040-3]
Number of Total Annual Responses: 267,032
Processing Time per Response: 20 minutes
Hourly Wage of Worker(s) Processing Responses: $15.68
Cost to Process Each Response: $5.23
Total Cost to Process Responses: $1,396,577.36
Part B: OPERATIONAL AND MAINTENANCE COSTS
Cost Categories
Equipment: $0
Printing: $
Postage: $0
Software Purchases: $0
Licensing Costs: $0
Other: $0
Total Operational and Maintenance Cost: $0
Part C: TOTAL COST TO THE FEDERAL GOVERNMENT
Total Labor Cost to the Federal Government: $1,396,577.36
Total Operational and Maintenance Costs: $0
Total Cost to the Federal Government: $1,396,577.36
15. Reasons for Change in Burden
There has been no change in burden since the previous approval.
16. Publication of Results
The results of this information collection will not be published.
17. Non-Display of OMB Expiration Date
We are not seeking approval to omit the display of the expiration date of the OMB approval on the collection instrument.
18. Exceptions to “Certification for Paperwork Reduction Submissions”
We are not requesting any exemptions to the provisions stated in 5 CFR 1320.9.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Kaitlin Chiarelli |
| File Modified | 0000-00-00 |
| File Created | 2022-06-29 |