SUPPORTING STATEMENT(Accident Incident-20 JUL 16)(2)X

SUPPORTING STATEMENT – PART A

Exchange Accident/Incident Reports (0702-XXXX)

1. JUSTIFICATION

1. Need for the Information Collection

The Army and Air Force Exchange Service (Exchange) is a Non-Appropriated Fund (NAF) instrumentality of the United States of America. Pursuant with Army Regulation 215-8/AFI 34-211(I) Chapter 13 and to adhere and resolve eligible patron issues and concerns, collection of information is required from the public to record incidents such as accidents, injuries, illnesses, mishaps, fires, theft or any issues involving government property. The recording of this information is necessary as a basis for payment of claims, providing medical treatment to those who are injured or ill, recovering damages on government property or assets, shoplifting and theft, and having supporting evidence in the event of legal actions.

The Secretary of Defense has vested in the Secretary of the Army and the Secretary of the Air Force all functions, powers, and duties relating to Exchange activities within their respective military departments. This authority is held jointly and equally. Army Regulation 215-8/Air Force Instruction 34-211(I), “Army and Air Force Exchange Service Operations”, in accordance with Title 10, U.S.C. §3013, “Secretary of the Army” and §8013, “Secretary of the Air Force”, charges the Army and Air Force Exchange Service (Exchange) with the responsibility of investigating and processing all accidents and incidences within the applicable department regulations. Executive Order 12196, “Occupational Safety and Health Programs for Federal Employees,” assures prompt abatement of all unsafe or unhealthy conditions. Executive Order 9397 (SSN), as amended allows the Exchange to collect Social Security Numbers in order to process such claims.

2. Use of the Information

The primary purpose of this collection is to gather all the required data and details from individuals at the time, or soon thereafter, of an alleged incident occurring at or on an Exchange facility/property. This may include accidents, injuries, illnesses, mishaps, fires, shoplifting, or issues involving damages to government property involving Exchange employees, patrons (customers), guests, visitors or contractors.

Information is provided by the individual verbally to an Exchange employee for input into the Exchange accident/incident database. 100% of witness statements are collected manually on Exchange Form 3900-017, “Statements” and then transferred to the Exchange Accident/Incident database. The statement section of the form may be verbatim per the witness’ account or the witness may choose to write the statement themselves. Exchange Form 3900-017 collects the individual’s name and other personal information along with their signature and abbreviations on each page. The accident incident report database is only accessible to designated Exchange personnel and not viewable by the individual. Once the Statement is finalized, it is printed out and a copy is provided to the individual for the purpose of reviewing, correcting, and authorizing the correctness of information. After the review process is completed, the individual initials each page of the statement and signs the last page as the interviewee.

Collected information varies depending on the nature or severity of the accident or incident. In all cases, the individual’s name is collected. Other collected personal information may include the individual’s home address, home phone number, cell number, e-mail address, date of birth, height, weight, race, social security number, and medical information such as physical ailments, medical reviews like x-rays and physical reports. Shoplifting or government property damage incidences may collect information relative to the individuals’ credit or financial means of repayment of damages, criminal background data and arrest records. Vehicle incidences collect information relative to the vehicle license number, insurance information, and pictures or videos of the alleged incident.

When Individuals voluntarily provide information, a loss prevention officer informs them of their privacy rights and provides them a privacy act statement to read. The individual is informed that refusal to provide information, concealment, or misrepresentation of material facts reported on Exchange Form 3900-017 may constitute grounds for employment separation for cause, disciplinary action, or civil or criminal litigation.

Information is collected by an Exchange loss prevention officer, contracted security officials, and/or Exchange facility managers and/or supervisors. The Exchange uses information collected to complete the investigation relative to the incident, provide victim medical treatment, pay claims, recoup damages to assets and property, correct deficiencies, and probable civil or criminal prosecution action.

3. Use of Information Technology

The information collected on Exchange Form 3900-017 is done so manually. Respondents cannot access or complete the form on-line and therefore the percentage of collecting information electronically is zero. The data collected on the form is prepared in the presence of an Exchange Loss Prevention Officer or other designated individual who verifies the data for accuracy and completeness. Additionally, Exchange Form 3900-017 requires a handwritten signature by both the respondent and the designated individual.

The use of technology enhances the ability of the Exchange to rapidly upload the data from Exchange Form 3900-017 to the Exchange accident/incident report database. To protect personal information maintained within the database, access is strictly prohibited to all individuals without an authorized need to know. The database allows immediate access to those designated Exchange employees “with authorized access” for purposes in addressing tort claims and recapturing funds associated with incidences resulting in damages.

Pursuant to the Privacy Act of 1974, as amended, Title 5 U.S.C. §552a, reports maintained in this system are readily available for disclosure to the individual or their designee upon request or for any investigatory or legal action as necessary or required.

4. Non-Duplication

This specific information is not available from other sources as it is collected only at the time of the incident.

5. Burden on Small Business

The collection of information does not have an impact on small businesses or other entities.

6. Less Frequent Collection

Information is collected from members of the public as an incident or accident occurs. This is collected “as needed” or “on occasion”. Less frequent collection is not possible.

7. Paperwork Reduction Act Guidelines

No special circumstances exist that require collection to be conducted in a manner inconsistent with the guidelines delineated in Title 5 CFR 1320.5(d)(2).

8. Consultation and Public Comments

1. A 60 Day Federal Register notice of the proposed collection was published in the Federal Register on May 20, 2016, 81 FRN 31918. No comments were received. A 30 Day Federal Register notice of the proposed collection was published in the Federal Register on August 11, 2016, 81 FRN 53128.

2. Significant input and information was received from the Exchange Force Protection directorate in relation to the continued use and burden relative to this collection. It was determined that the information is only maintained in one database and used accordingly as outlined in section 2 of this statement.

9. Gifts or Payment

No payments or gifts are offered to the respondents.

10. Confidentiality

The information is protected under the Privacy Act of 1974, as amended. Respondents are assured confidentiality verbally by the Exchange employee who collects the information. Access to information collected is restricted only to authorize Exchange personnel who have been screened, cleared for access, and have a role-based position which places them in an arrangement which requires servicing, reviewing or updating the record. Physical entry is restricted by the use of locks, guards, and passwords or other administrative procedures.

Disclosure of respondent information is made upon submission of the individuals’ original, notarized, written request for documents either disclosed to themselves or to a third party representative. Other disclosures may be made to law enforcement authorities for investigatory purposes or through the routine uses disclosures as authorized by statute. This system of records contains individually identifiable health information. The DoD Health Information Privacy Regulation (DoD 6025.18-R) issued pursuant to the Health Insurance Portability and Accountability Act of 1996, applies to such health information. DoD 6025.18-R may place additional procedural requirements on the uses and disclosures of such information beyond those found in the Privacy Act of 1974 or mentioned in the SORN. A draft copy of the altered SORN is provided.

All Exchange forms are currently being reviewed for updates by our forms manager to include the Agency Disclosure Notice, Privacy Act Statement (PAS) and basic instructions. In the interim, The Exchange will provide the Agency Disclosure Notice, Privacy Act Statement (PAS) and instructions in paper format prior to obtaining information from the individual.

The manual collection of accident and incident information does not require a Privacy Impact Assessment (PIA). The Exchange has presented a PIA for OMB’s review reflecting the APIS system which electronically maintains the collected information.

Exchange Form 3900-017 is maintained in a paper format for a period of 2 years after the accident or incident at which time they are destroyed by shredding. Electronic records maintained in the APIS system may be erased after a period of 2 years unless the accident or incident resulted in claims or payments at which point they are maintained for a period of 30 years.

11. Sensitive Questions

Respondents may be asked to provide age, height, weight, social security number, race, ethnicity, and possible physical behavioral attitudes or lifestyles, and medical history. These items may be used by medical providers or law enforcement entities in their treatment or investigation into alleged incident. The collection is authorized by DoD 5400.11-R, C4. If Social Security Number is requested and provided it is authorized under DoDI 1000.30 Enclosure 2 sections 2.c.(2)(6) and (8). Justification for use of the SSN is provided.

12. Respondent Burden and its Labor Cost

1. Estimation of Respondent Burden

The average annual burden estimate for reporting and recordkeeping requirements were derived from estimates from the Loss Protection directorate based upon the history of obtaining accident/incident information. It is estimated the Exchange collects information from 4,854 individuals during the course of a year. Each accident/incident occurrence only requires one response from the individual. The information is submitted by the individual during the interview on Exchange Form 3900-017.

Estimation of Respondent Burden Hours
	Number of Responses	Response Time per Response	Respondent Hourly Wage	Labor Burden per Response	Total Labor Burden
Form 3900-017 “Statement”	4,854	1	4,854	60 minutes	4,854 hours
Total	4,854	1	4,854	60 minutes	4,854 hours

2. Labor Cost of Respondent Burden

Each respondent is estimated to spend about 1 hour of time completing or being interviewed for data for completion of Exchange Form 3900-017. Using the 14 July 2009 United States Department of Labor Wage and Hour Division’s Federal Minimum wage of $7.25/hour (www.dol.gov/general/topic/wages/minimumwage), it is estimated the annual total labor cost to respondents is $35,191.50

Estimated Labor Cost of Respondent Burden
	Number of Responses	Response Time per Response	Respondent Hourly Wage	Labor Burden per Response	Total Labor Burden
Exchange Form 3900-017 “Statement”	4,854	60 Minutes	$7.25/Hour	$7.25	$35,191.50
Total	4,854	60 Minutes	$7.25/Hour	$7.25	$35,191.50

13. Respondent Costs Other Than Burden Hour Costs

There are no capital or start-up costs associated with this information collection.

14. Cost to the Federal Government

The estimated costs for the required recordkeeping and reporting activities were derived from consultations with the Loss Prevention Directorate. It is estimated the Exchange utilizes loss prevention officers across the world as well as those located at the HQ Exchange. This amounts to an approximately 91 employees with an average salary of $24.00 per hour (NAF Wage Schedule – 152 Dallas, TX Effective 08 Jun 2015). It takes approximately 1 hour to obtain the information and input into the database.

Estimated Labor Cost to the Federal Government (Non-Appropriated)
	Exchange Form 3900-017 “Statement”	TOTAL
Number of Responses	4,854	4,854
Processing Time per Response	60 Minutes	60 Minutes
Hourly Wage of Worker(s) Processing Responses	$24.00	$24.00
Cost to Process Each Response	$24.00	$24.00
Total Cost to Process Responses	$116,496	$116,496

Estimated Operational and Maintenance Costs
Equipment	Printing	Postage	Software Purchases	Licensing Costs	Other	Total
$5,000	$2,500	$250.00	$933,292	$2,600	$50,026	$993,668

Total Cost to the Federal Government
Operational and Maintenance Costs	Labor Cost to the Federal Government	Total Cost (O&M Costs + Labor Cost)
$ 993,668	$116,496	$1,110,164

15. Reasons for Change in Burden

This is an existing collection in use without an OMB Control Number.

16. Publication of Results

There are no plans to publish the results of this collection.

17. Non-Display of OMB Expiration Date

There is no request for approval to omit the display of the expiration date of the OMB approval on the instrument.

18. Exceptions to “certification for Paperwork Reduction Submissions”

There are no exceptions.

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