TRICARE Retiree Dental Program Enrollment Appication

Forms and Documents

Document Name	Status
Form Delta Dental Form TRICARE Retiree Dental Program Enrollment Appication Form	Modified
Supporting statement for TRDP Form.docx Supporting Statement A	2012-08-01

IC Document Collections

IC ID	Document Title	Status
5586	TRICARE Retiree Dental Program Enrollment Appication Form	Modified

ICR Details

OMB Control No: 0720-0015	ICR Reference No: 201207-0720-003
Status: Historical Active	Previous ICR Reference No: 200708-0720-003
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: TRICARE Retiree Dental Program Enrollment Appication
Type of Information Collection: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 08/27/2012
	Date Received in OIRA: 07/05/2012
Terms of Clearance: Approved consistent with the following terms of clearance: the DoD shall take care in future submissions to submit requests for extensions in a timely manner in order to avoid violating the Paperwork Reduction Act.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2015	36 Months From Approved
Responses	64,000	0	0
Time Burden (Hours)	16,000	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: This information is completed by Uniformed Service members entitled to retired pay and their eligible family members who are seeking enrollment in the TRICARE Retiree Dental Program (TRDP). The information is necessary to enable the DoD-contracted third party administrator of the program to identify the program's applicants, determine their eligibiity for TRDP enrollment, establish the premium payment amount, and verify by the applicant's signature that the applicant understands the benefits and rules of the program.

---

Authorizing Statute(s): US Code: 10 USC 1076c Name of Law: null
  

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:
	75 FR 60418	09/30/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 25710	05/01/2012
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
TRICARE Retiree Dental Program Enrollment Appication	Delta Dental Form	TRICARE Retiree Dental Program Enrollment Application

---

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	64,000	0	0	0	-7,332	71,332
Annual Time Burden (Hours)	16,000	0	0	0	-1,833	17,833
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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Decrease in respondents due to a miscalculation. The form has an updated Privacy Act Statement, an updated Agency Disclosure Notice, and reference to Discover as a payment method.

---

Annual Cost to Federal Government: $0

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]? 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? Uncollected

---

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: 07/05/2012

---