Information Collection

Durable Medical Equipment and Other Devices form

IC 223812 under ICR 202408-0420-003 · OMB 0420-0559.

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
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
Justification for revised DME_Final 1_25_16.docx Justification for changes	IC Document
DME Form - OMB changes.docx Changes to form	IC Document
DME Form - OMB changes.docx Changes to form	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? Yes

IC Status: Unchanged

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: 400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Potential Violation of the PRA
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	100	100
Annual IC Cost Burden (Dollars)	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.