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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:

	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

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.

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

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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

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

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

ICR Summary of Burden

	Total Approved	Change Due to Agency Discretion
Annual Number of Responses	400	400
Annual Time Burden (Hours)	100	100
Annual Cost Burden (Dollars)	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.

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

Agency Contact: Denora Miller 202 692-1236 dmiller4@peacecorps.gov

Common Form ICR: Yes
Description/Changes for Common Form Usage:

Approved RCFs using this ICR

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

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