32240 Federal Register / Vol. 79, No. 107 / Wednesday, June 4, 2014 / Notices 

DEPARTMENT OF DEFENSE 

Office of the Secretary 

[Docket ID DoD–2014–HA–0085] 

Proposed Collection; Comment 

Request 

AGENCY: Office of the Assistant 

Secretary of Defense for Health Affairs 

(DHA), DoD. 

ACTION: Notice. 

SUMMARY: In compliance with Section 

3506(c)(2)(A) of the Paperwork 

Reduction Act of 1995, the Office of the 

Assistant Secretary of Defense for 

Health Affairs (DHA) announces a 

proposed public information collection 

and seeks public comment on the 

provisions thereof. Comments are 

invited on: (a) Whether the proposed 

collection of information is necessary 

for the proper performance of the 

functions of the agency, including 

whether the information shall have 

practical utility; (b) the accuracy of the 

agency’s estimate of the burden of the 

proposed information collection; (c) 

ways to enhance the quality, utility, and 

clarity of the information to be 

collected; and (d) ways to minimize the 

burden of the information collection on 

respondents, including through the use 

of automated collection techniques or 

other forms of information technology. 

DATES: Consideration will be given to all 

comments received by August 4, 2014. 

ADDRESSES: You may submit comments, 

identified by docket number and title, 

by any of the following methods: 

• Federal eRulemaking Portal: http:// 

www.regulations.gov. Follow the 

instructions for submitting comments. 

• Mail: Federal Docket Management 

System Office, 4800 Mark Center Drive, 

East Tower, Suite 02G09, Alexandria, 

VA 22350–3100. 

Instructions: All submissions received 

must include the agency name, docket 

number and title for this Federal 

Register document. The general policy 

for comments and other submissions 

from members of the public is to make 

these submissions available for public 

viewing on the Internet at http:// 

www.regulations.gov as they are 

received without change, including any 

personal identifiers or contact 

information. 

Any associated form(s) for this 

collection may be located within this 

same electronic docket and downloaded 

for review/testing. Follow the 

instructions at http:// 

www.regulations.gov for submitting 

comments. Please submit comments on 

any given form identified by docket 

number, form number, and title. 

FOR FURTHER INFORMATION CONTACT: To 

request more information on this 

proposed information collection or to 

obtain a copy of the proposal and 

associated collection instruments, 

please write to Defense Health Agency, 

Medical Benefits and Reimbursement 

Branch (MB&RB), 16401 E. Centretech 

Parkway, Aurora, CO 80011–9066, or 

(303) 676–3565. 

SUPPLEMENTARY INFORMATION: 

Title; Associated Form; and OMB 

Number: TRICARE DoD/CHAMPUS 

Medical Claim—Patient’s Request for 

Medical Reimbursement; DD Form 

2642; OMB Control Number 0720–0006. 

Needs and Uses: This form is used 

solely by beneficiaries requesting 

reimbursement for medical expenses 

under the TRICARE Program. The 

information collected will be used by 

TRICARE/CHAMPUS to determine 

beneficiary eligibility; other health 

insurance eligibility; certification of the 

beneficiary eligibility and other health 

insurance liability; certification that the 

beneficiary received the care and 

reimbursement for the medical services 

received. 

Affected Public: Individuals or 

households. 

Annual Burden Hours: 750,000. 

Number of Respondents: 3,000,000. 

Responses per Respondent: 1. 

Total Annual Responses: 3,000,000. 

Average Burden per Response: 15 

minutes. 

Frequency: On occasion. 

This collection instrument is for use 

by beneficiaries under the TRICARE 

Program. TRICARE/CHAMPUS is a 

health benefits entitlement program for 

the dependents of active duty 

Uniformed Services members and 

deceased sponsors, retirees and their 

dependents, dependents of the 

Department of Homeland Security 

(Coast Guard) sponsors, and certain 

North Atlantic Treaty Organizations, 

National Oceanic and Atmospheric 

Administration, and Public Health 

Service eligible beneficiaries. DD Form 

2642 is used sole by TRICARE/ 

CHAMPUS beneficiaries to file for 

reimbursement of costs paid to 

providers and suppliers for authorized 

health care services or supplies. 

Dated: May 30, 2014. 

Aaron Siegel, 

Alternate OSD Federal Register Liaison 

Officer, Department of Defense. 

[FR Doc. 2014–12949 Filed 6–3–14; 8:45 am] 

BILLING CODE 5001–06–P 

DEPARTMENT OF DEFENSE 

Department of the Air Force 

[Docket ID: USAF–2013–0018] 

Submission for OMB Review; 

Comment Request 

ACTION: Notice. 

SUMMARY: The Department of Defense 

has submitted to OMB for clearance, the 

following proposal for collection of 

information under the provisions of the 

Paperwork Reduction Act (44 U.S.C. 

Chapter 35). 

DATES: Consideration will be given to all 

comments received by July 7, 2014. 

FOR FURTHER INFORMATION CONTACT: Fred 

Licari, 571–372–0493. 

SUPPLEMENTARY INFORMATION: 

Title, Associated Form And OMB 

Number: Air Force Safety Automated 

System (AFSAS); OMB Control Number 

0701–XXXX. 

Type Of Request: New Collection 

Number of Respondents: 200 

Responses per Respondent: 1 

Annual Responses: 200 

Average Burden per Response: 1 hour 

Annual Burden Hours: 200 

Needs And Uses: Information 

collected in the AFSAS includes 

individuals determined to be a factor in 

an Air Force (AF) or Department of 

Defense (DoD) mishap. The system 

meets DoD Instruction 6055.1 series 

reporting requirements governing 

aviation, space, weapons, and ground 

safety. Data collection includes 

personnel who are involved in a DoD 

related mishap, or experience an injury, 

illness or exposure while on a military 

installation or other areas under military 

control. It also includes personnel who 

operate a motorcycle on or off duty and 

personnel who operate a motorcycle on 

or off a DoD installation when in a duty 

status on official business. Data are used 

for analysis of safety risk and for 

prevention of mishaps. 

Affected Public: Individuals or 

Households 

Frequency: On occasion. 

Respondent’s Obligation: Voluntary. 

OMB Desk Officer: Ms. Jasmeet 

Seehra. 

Written comments and 

recommendations on the proposed 

information collection should be sent to 

Ms. Jasmeet Seehra at the Office of 

Management and Budget, Desk Officer 

for DoD, Room 10236, New Executive 

Office Building, Washington, DC 20503. 

You may also submit comments, 

identified by docket number and title, 

by the following method: 

• Federal eRulemaking Portal: http:// 

www.regulations.gov. Follow the 

instructions for submitting comments. 


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