SUPPORTING STATEMENT - PART A
Family Member Travel Screening – OMB Control Number 0704-0560
Summary of Changes from Previously Approved Collection
The DD Form x678 Series has been finalized as the DD Form 3040 series. SSN has been replaced with DoD ID Number on all of the forms.
Burden has increased due to a recalculation of the number of responses and widespread adoption of the forms across the Military Services.
1. Need for the Information Collection
The DD Forms 3040, 3040-1, 3040-2, 3040-3, and 3040-4 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), 10 USC 136 ‘Under Secretary of Defense for Personnel and Readiness,’ and the Department of Defense Instruction (DoDI) 1315.19, “The Exceptional Family Member Program (EFMP).” 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 screen family members of active duty Service members for special needs and 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 family travel screening component of the Assignment Coordination process for families relocating to remote or OCONUS locations. These forms document any travel concerns, which may include medical, dental, and/or educational needs, of dependents accompanying a Service member to assist in determining the availability of care at a gaining installation.
Throughout the family member 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, dental and educational providers who provide information about dependent medical, dental and educational needs; (3) FMTS Office staff who document any travel concerns, which may include 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 3040, 3040-1, 3040-2 and 3040-3 to active duty Service members with notification of an assignment to OCONUS and specific remote locations. The DD Form 3040-4 will remain at the FMTS Office for internal completion. As the respondents are exclusively DoD personnel charged with processing family member travel screenings, this form is not factored into the burden.
To complete the DD Forms 3040, 3040-1, 3040-2 and 3040-3, Service members may need to contact civilian medical and dental providers. DD Forms 3040 and 3040-1 are completed by the Service member for their dependents. The DD Form 3040-2 is required for all dependents over the age of 12 months, and is completed by dental providers. The DD Form 3040-3 is required for each dependent that receives care outside of a Military Treatment Facility as is completed by a qualified civilian medical provider. Once the forms are completed, they are delivered to FMTS Office staff. An in-person appointment is scheduled with the appointed FMTS medical screener, a qualified provider who will then complete the forms documenting any potential travel concerns, such as medical, dental, and/or educational needs.
3. Use of Information Technology
No responses are collected electronically. The forms are distributed as PDF-fillable forms and may be completed electronically but responses must be printed out and can only be submitted to the Family Member Travel Screening Office as hard copies.
4. Non-duplication
The information obtained through this collection is unique and is not already available for use or adaptation from another cleared source.
5. Burden on Small Businesses
This information collection does not impose a significant economic impact on a substantial number of small businesses or entities.
Medical and dental providers outside of the Military Services may be small business respondents. These respondents may be required to complete the DD Form 3040-2 or DD Form 3040-3. 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
Information is collected once for any OCONUS or remote PCS cycle for each dependent. If the information is not collected, there could be challenges determining the availability of care at installations. These challenges could result in the early return of dependents from their new duty location due to the unavailability of services and could negatively impact the military readiness of active duty Service members.
7. Paperwork Reduction Act Guidelines
This collection of information does not require collection to be conducted in a manner inconsistent with the guidelines delineated in 5 CFR 1320.5(d)(2).
8. Consultation and Public Comments
Part A: PUBLIC NOTICE
A 60-Day Federal Register Notice (FRN) for the collection published on Wednesday, October 24, 2018. The 60-Day FRN citation is 83 FRN 53613.
No comments were received during the 60-Day Comment Period.
A 30-Day Federal Register Notice for the collection published on Thursday, May 16, 2019. The 30-Day FRN citation is 84 FRN 22118.
Part B: CONSULTATION
No additional consultation apart from soliciting public comments through the Federal Register was conducted for this submission.
9. Gifts or Payment
No payments or gifts are being offered to respondents as an incentive to participate in the collection.
10. Confidentiality
Privacy Act Statements are provided to all respondents on each of the forms.
The Systems of Record Notices for this collection may be found online at the following links:
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/
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/
A Privacy Impact Assessment (PIA) is not required for this collection because PII is not being collected electronically.
Retention schedules are available in the links provided for the SORNs.
11. Sensitive Questions
These forms are used in the Assignment Coordination process for families relocating to remote or OCONUS locations. They are used to document any travel concerns, which may include 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 3040, 3040-1, 3040-2, 3040-3, and 3040-4 is considered sensitive. The purpose of the forms, however, requires that such information be collected so that the medical, dental and educational needs can be identified and coordinated with the overseas locations. Each form contains a Privacy Act Statement that explains to the respondent the necessity for collecting sensitive data.
12. Respondent Burden and its Labor Costs
Part A: ESTIMATION OF RESPONDENT BURDEN
[DD Form 3040 – Screening Verification]
Number of Respondents: 35,173
Number of Responses Per Respondent: 1
Number of Total Annual Responses: 35,173
Response Time: 10 minutes
Respondent Burden Hours: 5,862 hours
[DD Form 3040-1 – Medical and Educational Information]
Number of Respondents: 84,414
Number of Responses Per Respondent: 1
Number of Total Annual Responses: 84,414
Response Time: 30 minutes
Respondent Burden Hours: 42,207 hours
[DD Form 3040-2 – Dental Health Information]
Number of Respondents: 101,298
Number of Responses Per Respondent: 1
Number of Total Annual Responses: 101,298
Response Time: 15 minutes
Respondent Burden Hours: 25,324.5 hours
[DD Form 3040-3 – Patient Care Review]
Number of Respondents: 46,147
Number of Responses Per Respondent: 1
Number of Total Annual Responses: 46,147
Response Time: 15 minutes
Respondent Burden Hours: 11,636.75 hours
Total Submission Burden (Summation or average based on collection)
Total Number of Respondents: 267,032
Total Number of Annual Responses: 267,032
Total Respondent Burden Hours: 85,030.25 hours
Part B: LABOR COST OF RESPONDENT BURDEN
[DD Form 3040 – Screening Verification]
Number of Total Annual Responses: 35,173
Response Time: 10 minutes
Respondent Hourly Wage: $7.25
Labor Burden per Response: $1.21
Total Labor Burden: $42,559.33
[DD Form 3040-1 – Medical and Educational Information]
Number of Total Annual Responses: 84,414
Response Time: 30 minutes
Respondent Hourly Wage: $7.25
Labor Burden per Response: $3.625
Total Labor Burden: $306,000.75
[DD Form 3040-2 – Dental Health Information]
Number of Total Annual Responses: 101,298
Response Time: 15 minutes
Respondent Hourly Wage: $84.54
Labor Burden per Response: $21.135
Total Labor Burden: $2,140,933.23
[DD Form 3040-3 – Patient Care Review]
Number of Total Annual Responses: 46,147
Response Time: 15 minutes
Respondent Hourly Wage: $96.68
Labor Burden per Response: $24.17
Total Labor Burden: $1,115,372.99
Overall Labor Burden
Total Number of Annual Responses: 267,032
Total Labor Burden: $3,604,866.3
The Respondent hourly wage was determined by using the Federal minimum wage of $7.25/hr and the hourly wages for Dentists and General Practitioners, as applicable. (https://www.bls.gov/oes/current/oes_nat.htm)
13. Respondent Costs Other Than Burden Hour Costs
There are no annualized costs to respondents other than the labor burden costs addressed in Section 12 of this document to complete this collection.
14. Cost to the Federal Government
Part A: LABOR COST TO THE FEDERAL GOVERNMENT
[DD Form 3040-4 – Administrative Review Checklist]
Number of Total Annual Responses: 267,032
Processing Time per Response: 20 minutes
Hourly Wage of Worker(s) Processing Responses : $15.68
Cost to Process Each Response: $5.23
Total Cost to Process Responses: $1,396,577.36
Part B: OPERATIONAL AND MAINTENANCE COSTS
Cost Categories
Equipment: $0
Printing: $
Postage: $0
Software Purchases: $0
Licensing Costs: $0
Other: $0
Total Operational and Maintenance Cost: $0
Part C: TOTAL COST TO THE FEDERAL GOVERNMENT
Total Labor Cost to the Federal Government: $1,396,577.36
Total Operational and Maintenance Costs: $0
Total Cost to the Federal Government: $1,396,577.36
15. Reasons for Change in Burden
The burden has increased since the previous approval due to a recalculation of the number of responses. Use of the DD Form 3040 series has expanded as the Military Services have adopted the forms. The time burden on the DD Form 3040-1 has increased to 30 minutes from 20, but the number of responses for the DD Forms 3040-2 and 3040-3 have decreased. The labor cost of respondents has also been adjusted, as of data from May 2018.
16. Publication of Results
The results of this information collection will not be published.
17. Non-Display of OMB Expiration Date
We are not seeking approval to omit the display of the expiration date of the OMB approval on the collection instrument.
18. Exceptions to “Certification for Paperwork Reduction Submissions”
We are not requesting any exemptions to the provisions stated in 5 CFR 1320.9.
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