Active Duty Dental Program Claim Form

Forms and Documents

Document Name	Status
Form Form 5579 Active Duty Dental Program Claim Form Form	Modified
0720-0053_SS-A_12.19.19.doc Supporting Statement A	2019-12-19

IC Document Collections

IC ID	Document Title	Status
203005	Active Duty Dental Program Claim Form Form	Modified

ICR Details

OMB Control No: 0720-0053	ICR Reference No: 201912-0720-003
Status: Active	Previous ICR Reference No: 201604-0720-003
Agency/Subagency: DOD/DODOASHA	Agency Tracking No:
Title: Active Duty Dental Program Claim Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 01/28/2020
	Date Received in OIRA: 12/20/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2023	36 Months From Approved	01/31/2020
Responses	300,000	0	300,000
Time Burden (Hours)	75,000	0	75,000
Cost Burden (Dollars)	1,434,000	0	1,308,000

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Abstract: The information collection is necessary to obtain and record the dental readiness of Service Members using the Active Duty Dental Program (ADDP) and at the same time submit the claim form for the dental procedures provided. Many of these Service Members are not located near a military dental clinic and receive their dental care in the private sector under ADDP. The form is needed to update the dental readiness of all Service Members so that they can maintain worldwide deployment status and reduces paperwork by combining the dental claim and dental readiness into one form.

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Authorizing Statute(s): US Code: 10 USC 1074 Name of Law: Medical and Dental Care for Members and Certain Former Members
  

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:
	84 FR 41972	08/16/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 69730	12/19/2019
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
Active Duty Dental Program Claim Form	Form 5579	Active Duty Dental Program Claim Form

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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	300,000	300,000	0	0	0	0
Annual Time Burden (Hours)	75,000	75,000	0	0	0	0
Annual Cost Burden (Dollars)	1,434,000	1,308,000	0	126,000	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: $2,016,000

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.     No

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.     Yes

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

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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: 12/20/2019

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