Supporting Statement Outline – Sample
NOTE: Complete Part A for all ICR Requests
A. JUSTIFICATION
1. Need for the Information Collection
The DD Forms X678 TEST, X678-1 TEST, X678-2 TEST, X678-3 TEST, and X678-4 TEST are 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 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.
This standardized collection of information is required by the National Defense Authorization Act of 2010 (NDAA 2010) and the Department of Defense Instruction (DoDI) 1315.19, “Authorizing Special Needs Family Members Travel Overseas at Government Expense.” 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 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 are used by Service Personnel/Transferring Commands and the military medical departments in the travel screening component of the Assignment Coordination process for families relocating to remote or OCONUS locations. These forms document any special medical, dental, and/or educational needs of dependents accompanying a Service member to assist in determining the availability of care at a gaining installation. Previously, each military department has used department-specific forms for the FMTS process, which has caused challenges for determining the availability of care for military families at joint-Service or sister-Service gaining installations—ultimately decreasing the military readiness of active duty Service members. The DD Forms X678 TEST, X678-1 TEST, X678-2 TEST, X678-3 TEST, and X678-4 TEST are standardized across the four Services with the goal of simplifying and streamlining the travel screening process.
Throughout the Assignment Coordination travel screening process, form respondents include: (1) active duty Service members and/or dependents over the age of majority who provide demographic, medical, and educational information; (2) medical and dental providers who provide information about dependent medical and dental needs; (3) FMTS Office staff who document any special medical, dental, and/or educational needs and who document the availability of special needs support services at a gaining location. FMTS Office staff will distribute the DD Forms X678 TEST, X678-1 TEST, X678-2 TEST and X678-3 TEST to active duty Service members with PCS orders to specific OCONUS locations. The DD Form X678-4 TEST, Administrative Review Checklist, which does not collect any additional information from the public, will remain at the FMTS Office for internal review and completion; that is, the FMTS Office staff reviews the DD Form X678-DD Form X678-3 TEST to verify that they have been completed properly and then completes DD Form X678-4 TEST. To complete the DD Forms X678 TEST, X678-1 TEST, X678-2 TEST and X678-3 TEST, Service members may need to contact medical and dental providers. Once the forms are completed for the family, Service members will deliver the forms to FMTS Office staff, who will review and complete the forms to document any special medical, dental, and/or educational needs and the availability of special needs support services at a gaining location.
3. Use of Information Technology
Responses are not collected electronically during the FMTS Pilot. During the Pilot, the DD Forms X678 TEST, X678-1 TEST, X678-2 TEST, X678-3 TEST, and X678-4 TEST will be printed and completed by hand.
After the Pilot, the DD Forms may be distributed as PDF-fillable forms and completed electronically. This is intended to reduce the burden on respondents when transferring the forms to additional respondents. If a pilot of the forms demonstrates that the forms can integrate into Service-specific Assignment Coordination processes, then ways to electronically complete, collect, and store the forms will be considered.
4. Non-duplication
While demographic and some medical and educational records may be already available from various sources, there are no centralized records that contain all required information for the standardized family member travel screening process other than the DD Forms X678 TEST, X678-1 TEST, X678-2 TEST, X678-3 TEST, and X678-4 TEST. These forms were developed based on nine department-specific forms currently used during Service-specific travel screening processes. Department-specific forms will be used for families NOT participating in the Pilot. Only families participating in the Pilot will use the Pilot forms.
Medical and dental providers outside of the Military Services may be small business respondents. These respondents may be required to complete the DD Form X678-2 TEST or DD Form X678-3 TEST. 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
These forms are intended to be completed once per PCS cycle per dependent. If collection was conducted less frequently than once per PCS cycle, then there could be challenges with determining the availability of care at gaining installations. These challenges could result in the early return of families from their new duty location due to unavailability of services and could negatively impact the military readiness of active Service members.
7. Paperwork Reduction Act Guidelines
There are no special circumstances. This collection will be conducted in a manner consistent with the guidelines contained in 5 CFR 1320.5(d)(2).
8. Consultation and Public Comments
Part A: PUBLIC NOTICE
The FMTS forms were published in the Federal Register for 60 days from 26 January 2016 until 28 March 2016.
The 60 Day Federal Register Notice citation is 81 FRN 4266.
No comments were submitted during the 60 Day Federal Register Notice comment period.
A 30-Day Federal Register Notice for this collection published on October 6, 2016. The 30-Day FRN citation is 81 FR 69518.
Part B: CONSULTATION
OSN consulted with the four Military Services to develop the forms and consolidate the information gathered across nine department-specific forms. A pilot of the forms will provide additional insight into the clarity of instructions and ability of the forms to integrate with Service-specific Assignment Coordination processes. The forms will be continuously monitored and consultations will occur on an ongoing basis to ensure that the form is up-to-date for the FMTS process.
No payment or gift will be made to respondents.
10. Confidentiality
All data are protected by the Privacy Act of 1974 and are protected according to the regulations therein, and by related DoD directives and instructions. Where possible, steps have been taken to reduce the collection of Personal Health Information (PHI) on the forms. Any files containing PHI will be uploaded to the Sponsor’s medical records. All forms include a Privacy Act Statement, which notify the public of their privacy rights.
The data on the forms is covered in several SORNS:
Department of Defense (DoD)
DMDC 02 DoD: Defense Enrollment Eligibility Reporting Systems (DEERS)
SORN Website: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/627618/dmdc-02-dod/
EDHA 07: Military Health Information System
SORN Website: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570672/edha-07/
DPR 34 DoD: Defense Civilian Personnel Data System
SORN Website: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570697/dpr-34-dod/
Department of Defense Education Activity (DoDEA)
DoDEA 26: DoDEA Educational Records
SORN Website: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570573/dodea-26/
DoDEA 29: DoDEA Non-DoD Schools Program
SORN Website: http://dpcld.defense.gov/Privacy/SORNsIndex/DOD-wide-SORN-Article-View/Article/570576/dodea-29/
Privacy Impact Assessment (PIA): A PIA is not required because PII is not being collected and stored electronically.
Retention schedule available through the links provided for SORNs.
11. Sensitive Questions
These forms are used in the Assignment Coordination process for families relocating to remote or OCONUS locations. These forms 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.
All of the information on the DD Forms X678 TEST, X678-1 TEST, X678-2 TEST, X678-3 TEST, and X678-4 TEST is considered sensitive. The purpose of the forms, however, requires that such information be collected so that the medical and educational needs can be identified and met at overseas locations. Each form contains a Privacy Act Statement that explains to the respondent the necessity for collecting sensitive data.
Personal Identifying Information (PII): Respondents are advised that their data are for OFFICIAL USE ONLY and will be maintained and used in strict confidence and in accordance with Federal law and regulations. Procedures are in place to protect the confidentiality of the information. The paper forms will be secured to protect PII in accordance with DoD regulations.
Social Security Numbers (SSN): The SSN of the Service member on the DD Forms X678 TEST, X678-1 TEST, X678-2 TEST, X678-3 TEST, and X678-4 TEST is used because the military personnel systems and the MHS Legacy Systems still use SSN as a record key for both medical records and personnel files. This is an identified acceptable use for SSNs as defined by DoDI 1000.30, Acceptable Use 11, Legacy System Interface.
Collection of the Social Security Number (SSN) is necessary to link the document to the Service member’s personnel records. The SSN of the Service member (and Service member’s spouse if dual military) allows the Military Healthcare System (MHS) and Service personnel offices to collaborate in determining if any identified special needs of the Service member’s dependent(s) must be considered during assignment planning and coordination. Information that a Service member has a dependent with special needs is noted in the official military personnel files which are retrieved by name and SSN.
If the DoD does not collect the SSN from the Service member, there is an unacceptable risk that the medical information may be incorrectly annotated in the wrong Sponsor’s file. A Sponsor might then be assigned to a location where the family member’s medical need could not be met, resulting in lack of necessary medical services, and possible return of the family to a location with adequate services.
Where possible, the DD Forms X678-2 TEST and X678-3 TEST request a truncated version of the Sponsor’s SSN to limit the use of SSNs.
Sensitive Questions (i.e., sexual behavior or attitudes, religious beliefs, race and/or ethnicity race and ethnicity): Not applicable.
12. Respondent Burden, and its Labor Costs
a. Estimation of Respondent Burden
Estimation of Respondent Burden Hours |
|||||
|
Number of Respondents The X678-2 and X678-3 are completed by multiple respondents |
Number of Responses per Respondent |
Number of Total Annual Responses |
Response Time |
Respondent Burden Hours |
DD Form X678 TEST Screening Verification |
1,887 Family Members |
1 |
1,887 |
30 minutes |
944 hours |
DD Form X678-1 TEST Medical and Educational Information |
4,718 Family Members |
1 |
4,718 |
30 minutes |
2,359 hours |
DD Form X678-2 TEST Dental Health Information |
4,246 Family Members |
1 |
4,246 |
1.5 minutes |
106 hours |
2,579 Civilian Dentists |
1 |
2,579 |
13.5 minutes |
580 hours |
|
DD Form X678-3 TEST Patient Care Review |
1,934 Family Members |
1 |
1,934 |
1.5 minutes |
48 hours |
2,579 Civilian Physicians |
1 |
2,579 |
13.5 minutes |
580 hours |
|
Total |
17,943 |
1 |
17,943 |
Avg. |
4,617 hours |
*NOTE: The DD Forms X678 and X678-1 each take 30 minutes to complete. However, the family only completes a portion of those forms, which would take 10 and 20 minutes, respectively, for a family to complete.
Labor Cost of Respondent Burden |
|||||
|
Number of Responses |
Response Time per Response |
Respondent Hourly Wage |
Labor Burden per Response (Response Time multiplied by Respondent Hourly Wage) |
Total Labor Burden (Number of Respondents multiplied by Response Time multiplied by Respondent Hourly Wage) |
DD Form X678 TEST Screening Verification |
1,887 Family Members |
30 minutes* |
$22.71 |
$11.36 |
$21,427 |
DD Form X678-1 TEST Medical and Educational Information |
4,718 Family Members |
30 minutes* |
$22.71 |
$11.36 |
$53,573 |
DD Form X678-2 TEST Dental Health Information |
4,246 Family Members |
1.5 minutes |
$22.71 |
$0.57 |
$2,411 |
2,579 Civilian Dentists |
13.5 minutes |
$80.20 |
$18.04 |
$46,539 |
|
DD Form X678-3 TEST Patient Care Review |
1,934 Family Members |
1.5 minutes |
$22.71 |
$0.57 |
$1,098 |
2,579 Civilian Physicians |
13.5 minutes |
$89.58 |
$20.16 |
$51,982 |
|
Total |
17,943 |
Avg. |
$260.62 |
$62.06 |
$177, 030 |
*NOTE: The DD Forms X678 and X678-1 each take 30 minutes to complete. However, the family only completes a portion of those forms, which would take 10 and 20 minutes, respectively, for a family to complete.
The mean hourly wages for family members, physician providers, and dental providers are according to the Department of Labor 2014 Bureau of Labor Statistics.
13. Respondent Costs Other Than Burden Hour Costs
There are no other annualized costs to respondents other than the labor burden costs addressed in Item 12.
14. Cost to the Federal Government
Processing for the DD Forms, X678 TEST, X678-1 TEST, X678-2 TEST, and X678-3 TEST is guided by the DD Form X678-4 TEST Administrative Review Checklist. The processing time per response for each form in the table below is derived from the time for a DoD employee to complete the DD Form X678-4 TEST.
The hourly wage was calculated using the average position level for Personnel (E-2 to E-6) and the Army 2013 Demographics Report.
|
DD Form X678 TEST |
DD Form X678-1 TEST |
DD Form X678-2 TEST |
DD Form X678-3 TEST |
Total |
Number of Responses |
2,516 |
6,290 |
5,661 |
2,579 |
17,046 |
Processing Time Per Response (in hours) |
.083 |
.083 |
.083 |
.083 |
0.332 |
Hourly Wage of Worker(s) Processing Responses |
$15.61 |
$15.61 |
$15.61 |
$15.61 |
$62.44 |
Cost to Process Each Response (Processing Time Per Response multiplied by Hourly Wage of Worker(s) Processing Responses) |
$1.30 |
$1.30 |
$1.30 |
$1.30 |
$5.20 |
Total Cost to Process Responses (Cost to Process Each Response multiplied by Number of Responses |
$3,270.80 |
$8,177 |
$7359.30 |
$3,352.70 |
$22,159.80 |
Operational and Maintenance Costs |
||||||
Equipment |
Printing |
Postage |
Software Purchases |
Licensing Costs |
Other |
Total |
N/A* |
$2075.70** |
N/A* |
N/A* |
N/A* |
N/A* |
$2,075.70 |
*NOTE: Processing of the forms uses existing resources and
does not require postage.
**NOTE: Printing costs were
estimated at $.05 per page. However, the Pilot forms are printed
INSTEAD OF existing screening forms for families participating in the
Pilot, thus adding no additional cost to the government to print.
Total Cost to the Federal Government |
||
Operational and Maintenance Costs |
Labor Cost to the Federal Government |
Total Cost (O&M Costs + Labor Cos t) |
$2,075.70 |
$22,159.80 |
$24,235.50 |
15. Reasons for Change in Burden
This is a new collection with a new associated burden.
16. Publication of Results
The results of the information collection will not be published as a DoD publication or for publication external to DoD.
17. Non-Display of OMB Expiration Date
The non-display of the expiration date of OMB approval on the collection instruction is not being requested.
18. Exceptions to "Certification for Paperwork Reduction Submissions"
No exemptions to the provisions certified.
| File Type | application/msword |
| Author | Patricia Toppings |
| Last Modified By | Mayra Dalence |
| File Modified | 2016-10-06 |
| File Created | 2016-10-06 |