Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
340B Program Registrations & Certifications for Children's Hospitals Modified 80 20 0 Form and Instruction 340B- 9a Hospital Registration Form
Form and Instruction 340B -9b Certification of State/Local Contract
Form and Instruction 340B -9c Certification of Non GPO
340B Program Registrations & Certifications for Disproportionate Share Hospitals Modified 1606 402 0 Form and Instruction 340b-10a Hospital Registration
Form and Instruction 340B-10b Certification of State/Local Contract
Form and Instruction 340B-10c Certification of Non GPO
340B Registration for all other covered entities Modified 170 14 0 Form and Instruction 340B 1 340B Registration Form
Administrative Change Form Modified 460 38 0 Form and Instruction 340B-6 Administrative Change Form
Annual Recertificaion for STD & TB Modified 1221 101 0 Other-Screenshot for electronic re-certification
Annual Recertification for Family Planning Modified 3995 332 0 Other-Screenshot for electronic Re-certification
Annual Recertification for Other Entities Modified 4000 332 0 Other-Screenshot for electronic re-certification
Certification to Enroll DSH and Children's Hospitals' Outpatient facilities to 340B Program Modified 2039 169 0 Form and Instruction 340B-3a DSH Outpatient Form
Form and Instruction 340B -3b Children's Hospital Outpatient Form
Contract Pharmacy Self Certification Form Modified 2000 166 0 Form and Instruction 340B -7 Contract Pharmacy Self-Certification Form
Hospital Annual Recertification Modified 2473 1237 0 Other-Screenshot for electronic re-certification
Total burden requested under this ICR: 18044 2811 0  
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