Changes to DME form

Applicant Name

(Last, First, Middle Initial)

Date of Birth___________/_________ /___________

(Month/Day/Year)

DURABLE MEDICAL EQUIPMENT AND OTHER DEVICES FORM

You have reported a condition that requires the use of a Medical Device. This form must be completed and all question answered that pertain to the device(s) you use. Please do not leave any question blank, as information helps determine where we can appropriately place you for service. If you use multiple medical devices, please complete the form for all devices.

PRIVACY ACT NOTICE

This information is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq. It will be used primarily for the purpose of determining your eligibility for Peace Corps service and, if you are invited to service as a Peace Corps Volunteer, for the purpose of providing you with medical care during your Peace Corps service. Your disclosure of this information is voluntary; however, your failure to provide this information or failure to disclose relevant information may result in the rejection of your application to become a Peace Corps Volunteer.

This information may be used for the purposes described in the Privacy Act, 5 U.S.C. 552a, including the routine uses listed in the Peace Corps’ System of Records. Among other uses, this information may be used by those Peace Corps staff members who have a need for such information in the performance of their duties. It may also be disclosed to the Office of Workers’ Compensation Programs in the Department of Labor in connection with claims under the Federal Employees’ Compensation Act and, when necessary, to a physician, psychiatrist, clinical psychologist, licensed clinical social worker or other medical personnel treating you or involved in your treatment or care. A full list of routine uses for this information can be found on the Peace Corps website at http://multimedia.peacecorps.gov/multimedia/pdf/policies/systemofrecords.pdf.

BURDEN STATEMENT

Public reporting burden for this collection of information is estimated to average 15 minutes per applicant and 10 minutes per physician per response. This estimate includes the time for reviewing instructions and completing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: FOIA Officer, Peace Corps, 1111 20th Street, NW, Washington, DC, 20526 ATTN: PRA (0420-0550). Do not return the complete form to this address.

Peace Corps – Durable Medical Equipment and Other Devices Form PC‐262-3 (Previous editions are obsolete) Page 1 of 3

First Medical Device:

 Prosthetic equipment	If prosthetic or orthotic equipment, list type: ________ _____________________________________________
 Orthotic equipment
 Insulin pump
 C-Pap Machine
 Hearing Aid  Cochlear implant
 Wheelchair
 Walker/Crutches/Cane
 Other: _____________________________________

Make and Model: ___________________________________________________________________________________

Rental/Lease  Yes  No

Warranty Information: _______________________________________________________________________________

Date of last maintenance: __________ ____________ Expected date of next maintenance: _______________________

Back-up plan should this device fail due to environmental challenges: _________________________________________

__________________________________________________________________________________________________

Second Medical Device:

 Prosthetic equipment	If prosthetic or orthotic equipment, list type: ________ _____________________________________________
 Orthotic equipment
 Insulin pump
 C-Pap Machine
 Hearing Aid  Cochlear implant
 Wheelchair
 Walker/Crutches/Cane
 Other: _____________________________________

Make and Model: ___________________________________________________________________________________

Rental/Lease  Yes  No

Warranty Information: _______________________________________________________________________________

Date of last maintenance: __________ ____________ Expected date of next maintenance: _______________________

Back-up plan should this device fail due to environmental challenges: _________________________________________

__________________________________________________________________________________________________

Peace Corps – Durable Medical Equipment and Other Devices Form PC‐262-3 (Previous editions are obsolete) Page 2 of 3

Third Medical Device:

 Prosthetic equipment	If prosthetic or orthotic equipment, list type: ________ _____________________________________________
 Orthotic equipment
 Insulin pump
 C-Pap Machine
 Hearing Aid  Cochlear implant
 Wheelchair
 Walker/Crutches/Cane
 Other: _____________________________________

Make and Model: ___________________________________________________________________________________

Rental/Lease  Yes  No

Warranty Information: _______________________________________________________________________________

Date of last maintenance: __________ ____________ Expected date of next maintenance: _______________________

Back-up plan should this device fail due to environmental challenges: _________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

Peace Corps – Durable Medical Equipment and Other Devices Form PC‐262-3 (Previous editions are obsolete) Page 3 of 3