Professional Qualifications, Medical and Peer Reviewers

Forms and Documents

Document Name	Status
Form DHA 780 Professional Qualifications Medical/Peer Reviewers Form	Modified
0720-0005_SS-A_02.26.2021.docx Supporting Statement A	2021-02-26
CCQAS DD Form 2930 (PIA) FINAL 08122020.pdf Supplementary Document	2021-02-25
TRICARE Operations Manaual Chapter 12 Adendum A.pdf Supplementary Document	2017-01-18

IC Document Collections

IC ID	Document Title	Status
5569	Professional Qualifications Medical/Peer Reviewers Form	Modified

ICR Details

OMB Control No: 0720-0005	ICR Reference No: 202102-0720-001
Status: Received in OIRA	Previous ICR Reference No: 201701-0720-001
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Professional Qualifications, Medical and Peer Reviewers
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 02/26/2021

	Requested	Previously Approved
Expiration Date	36 Months From Approved	02/28/2021
Responses	60	60
Time Burden (Hours)	20	20
Cost Burden (Dollars)	2,000	1,800

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Abstract: The information collection requirement is necessary to obtain and record the profesional qualifications of medical and peer reviews utilized within TRICARE. The form is included as an exhibit in an appeal or hearing case file as evidence of the reviewer's professional qualifications to review the medical documentation contained in the case file.

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Authorizing Statute(s): None

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:
	85 FR 77186	12/01/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 11734	02/26/2021
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
Professional Qualifications Medical/Peer Reviewers	DHA 780	Professional Qualifications Medical Peer Reviewers

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ICR Summary of Burden

	Total Request	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	60	60	0	0	0	0
Annual Time Burden (Hours)	20	20	0	0	0	0
Annual Cost Burden (Dollars)	2,000	1,800	0	200	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: $99

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.     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? 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: 02/26/2021

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