Information Collection

Durable Medical Equipment and Other Devices form

IC 223812 under ICR 202011-0420-005 · OMB 0420-0559.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0420-0559 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form PC-262-3 Durable Medical Equipment and Other Devices form	Form and Instruction
PC-262-3 Durable Medical Equipment Form DME Form - OMB changes.docx	Form and Instruction
Justification for revised DME_Final 1_25_16.docx Justification for changes	IC Document
DME Form - OMB changes.docx Changes to form	IC Document

IC Title:

Durable Medical Equipment and Other Devices form

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	PC-262-3	Durable Medical Equipment Form	DME Form - OMB changes.docx		Yes	Yes	Fillable Fileable

Line of Business: International Affairs and Commerce

Subfunction: International Development and Humanitarian Aid

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 154

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	154	-246	400
Annual IC Time Burden (Hours)	64	-36	100
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Justification for changes	Justification for revised DME_Final 1_25_16.docx	02/07/2017
Changes to form	DME Form - OMB changes.docx	02/14/2017

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.