Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
340B Program Registrations amp; Certifications for Children's Hospitals Modified 12 24 0 Form and Instruction 1
Form and Instruction 3
Form and Instruction 4
Form and Instruction 2
340B Program Registrations amp; Certifications for Disproportionate Share Hospitals Modified 330 660 0 Form and Instruction 3
Form and Instruction 2
Form and Instruction 4
Form and Instruction 1
340B Program Registrations amp; Certifications for Free Standing Cancer Hospitals Modified 8 16 0 Form and Instruction 1
340B Program Registrations amp; Certifications for Sole Community Hospitals Modified 60 120 0 Form and Instruction 1
340B Program Registrations and Certifications for Critical Access Hospitals Modified 88 176 0 Form and Instruction 1
340B Registration for all other covered entities Modified 606 606 0 Form and Instruction 1
34B Program Registrations amp; Certifications for Rural Referral Hospitals Modified 48 96 0 Form and Instruction 1
Administrative Change Form Modified 2500 1250 0 Form and Instruction 1
Administrative Changes for Any Manufacturer Modified 350 175 0 Form and Instruction 1
Annual Recertificaion for STD amp; TB Modified 2754 1377 0 Form and Instruction 1
Form and Instruction 2
Annual Recertification for Family Planning Modified 3879 1940 0 Form and Instruction 1
Annual Recertification for Other Entities Modified 5681 2841 0 Form and Instruction 1
Certification to Enroll DSH and Children's Hospitals' Outpatient facilities to 340B Program Modified 606 303 0 Form and Instruction 1
Contract Pharmacy Self Certification Form Modified 2500 2500 0 Form and Instruction 1
Hospital Annual Recertification Modified 4842 2421 0 Form and Instruction 1a
Form and Instruction 1b
Pharmaceutical Pricing Agreement Modified 200 200 0 Other-Program Agreement Form
Total burden requested under this ICR: 24464 14705 0  
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