Durable Medical Equipment (DME).

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form PC-262-3 Durable Medical Equipment and Other Devices form	Form and Instruction	New	Repair queued
Justification for revised DME_Final 1_25_16.docx	Supplementary Document	Uploaded 2017-02-14	Available
DME Form - OMB changes.docx	Supplementary Document	Uploaded 2017-02-14	Available
DME Supporting Statement_final.docx	Supporting Statement A	Uploaded 2017-02-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
223812	Durable Medical Equipment and Other Devices form	Form and Instruction	New

ICR Details

OMB Control No: 0420-0559	ICR Reference No: 201610-0420-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: PEACE	Agency Tracking No:
Title: Durable Medical Equipment (DME).
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  Yes
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/28/2017
	Date Received in OIRA: 11/18/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2020	36 Months From Approved
Responses	400	0	0
Time Burden (Hours)	100	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Durable Medical Equipment (DME) is any equipment that provides therapeutic benefits to a patient in need because of certain medical conditions and/or illness. They consist of items that are primarily and customarily used to serve a medical purpose; are not useful to a person in the absence of illness or injury; are ordered or prescribed by a physician; are reusable; can stand repeated use, and are appropriate for use in the home. Other devices covered in this guidance include prosthetic equipment (cardiac pacemakers), hearing aids, orthotic items (artificial devices such as braces and splints), and prostheses (artificial body parts). The information collected will assist in the determination of Peace Corps eligibility. If eligible, it will assist with ongoing care during service. All applicants to the Peace Corps must have a medical clearance that will determine their ability to serve in a particular country.

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Authorizing Statute(s): US Code: 22 USC 2501 et seq Name of Law: Peace Corps Act
  

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:
	81 FR 11844	03/07/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 63506	09/15/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Durable Medical Equipment and Other Devices form	PC-262-3	Durable Medical Equipment Form

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ICR Summary of Burden

table that charts list 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	400	0	0	400	0	0
Annual Time Burden (Hours)	100	0	0	100	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: All applicants to the Peace Corps must have a medical clearance that will determine their ability to serve in a particular country. This information is collected under the authority of the Peace Corps Act, 22 U.S.C.2501 et seq. This information may be used for the purposes described in the Privacy Act, 5 USC 552A, including the routines uses listed in the Peace Corps’ System of Records.Questions of a sensitive nature are asked solely from a medical perspective and the information gathered is used to determine whether the Applicant will, with reasonable accommodation, be able to perform the essential functions of a Peace Corps Volunteer and complete a tour of service without undue disruption due to health problems. This information also assists the Peace Corps in determining what is needed in order to provide adequate medical support to the Applicant during service. Peace Corps Volunteers serve in countries that have a different healthcare infrastructure than that found in the United States. Therefore, it is essential to fully understand each Applicant’s complete medical history, treatments and response to treatment, as well as a baseline evaluation of all conditions. Failure to answer truthfully could result in disqualification from Peace Corps service. The Peace Corps complies with the medical confidentiality requirements of the Privacy Act and HIPAA. However, all Applicants are required, as a condition of processing their applications and of Peace Corps service, to sign an Authorization for Peace Corps Use of Medical Information under which the Applicant permits the Peace Corps to use the Applicant’s protected health information to determine the Applicant’s eligibility for the Peace Corps and as necessary for administration of the Peace Corps program.

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Annual Cost to Federal Government: $1,533

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? 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? Uncollected

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Common Form ICR:  Yes

Description/Changes for Common Form Usage: 

Approved RCFs using this ICR

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Agency/Sub Agency	RCF ID	RCF Title	RCF Status	IC Title

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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: 11/18/2016

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