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 340B Registration Children's and Free Standing Cancer Hospitals revised
Form and Instruction 3 Cert state or local government Revised
Form and Instruction 4 Public OWNERSHIP Revised
Form and Instruction 2 GPO FOrm
340B Program Registrations amp; Certifications for Disproportionate Share Hospitals Modified 330 660 0 Form and Instruction 3 GPO Form
Form and Instruction 2 Cert state or local government Revised
Form and Instruction 4 Public OWNERSHIP Revised
Form and Instruction 1 340B Registration DSH
340B Program Registrations amp; Certifications for Free Standing Cancer Hospitals Modified 8 16 0 Form and Instruction 1 340B Registration Childrens and Free Standing Cancer Hospitals
340B Program Registrations amp; Certifications for Sole Community Hospitals Modified 60 120 0 Form and Instruction 1 340B Registration-RRC and SCH Revised
340B Program Registrations and Certifications for Critical Access Hospitals Modified 88 176 0 Form and Instruction 1 340B Registration-CAH Revised
340B Registration for all other covered entities Modified 606 606 0 Form and Instruction 1 340BRegistration-Covered Entities All Other Revised
34B Program Registrations amp; Certifications for Rural Referral Hospitals Modified 48 96 0 Form and Instruction 1 340B Registration-RRC and SCH Revised
Administrative Change Form Modified 2500 1250 0 Form and Instruction 1 340B Participatant Change Request Revised
Administrative Changes for Any Manufacturer Modified 350 175 0 Form and Instruction 1 340BManufacturerChangeForm Revised
Annual Recertificaion for STD amp; TB Modified 2754 1377 0 Form and Instruction 1 STD-Recert
Form and Instruction 2 TB-Recertification
Annual Recertification for Family Planning Modified 3879 1940 0 Form and Instruction 1 FP-Recert
Annual Recertification for Other Entities Modified 5681 2841 0 Form and Instruction 1 RW-Recert
Certification to Enroll DSH and Children's Hospitals' Outpatient facilities to 340B Program Modified 606 303 0 Form and Instruction 1 340B Registration-Outpatient Facility Revised
Contract Pharmacy Self Certification Form Modified 2500 2500 0 Form and Instruction 1 Contract Pharmacy Registrationform Revised
Hospital Annual Recertification Modified 4842 2421 0 Form and Instruction 1a Hospital Recertification
Form and Instruction 1b Recert Attestation
Pharmaceutical Pricing Agreement Modified 200 200 0 Other-Program Agreement Form
Total burden requested under this ICR: 24464 14705 0  
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