TRICARE Young Adult Application

Forms and Documents

Document Name	Status
Form ddx605 TRICARE Young Adult Application Form	New
Supporting Statement.doc Supporting Statement A	2011-03-22

IC Document Collections

IC ID	Document Title	Status
197033	TRICARE Young Adult Application Form	New

ICR Details

OMB Control No: 0720-0049	ICR Reference No: 201105-0720-001
Status: Historical Active	Previous ICR Reference No: 201103-0720-001
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: TRICARE Young Adult Application
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/02/2011
	Date Received in OIRA: 05/02/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2011	6 Months From Approved
Responses	32,000	0	0
Time Burden (Hours)	8,000	0	0
Cost Burden (Dollars)	0	0	0

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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.

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Authorizing Statute(s): PL: Pub.L. 111 - 383 702 Name of Law: null
  

Citations for New Statutory Requirements: PL: Pub.L. 111 - 383 702 Name of Law: null

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
0720-AB48	Final or interim final rulemaking	76 FR 23479	04/27/2011

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
TRICARE Young Adult Application	ddx605	TRICARE YOUNG ADULT APPLICATION

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ICR Summary 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	32,000	0	32,000	0	0	0
Annual Time Burden (Hours)	8,000	0	8,000	0	0	0
Annual Cost Burden (Dollars)	0	0	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: New collection.

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Annual Cost to Federal Government:

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

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? Uncollected

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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: 03/22/2011

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