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 3 Cert state or local government Revised
Form and Instruction 4 Public OWNERSHIP Revised
Form and Instruction 2 GPO FOrm
Form and Instruction 1 2 340B Registration for Children's Hospitals
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 1 340B Registration-DSH
340B Program Registrations amp; Certifications for Free Standing Cancer Hospitals Modified 8 16 0 Form and Instruction 1 12 340B Registration Free Standing Cancer Hospitals (Orphan Drug)
340B Program Registrations amp; Certifications for Rural Referral Hospitals Modified 48 96 0 Form and Instruction 1 13+14 340B Registration Rural Referral Centers and Sole Community Hospitals (Orphan Drug)
340B Program Registrations amp; Certifications for Sole Community Hospitals Modified 60 120 0 Form and Instruction 1 13+14 340B Registration Rural Referral Centers and Sole Community Hospitals (Orphan Drug)
340B Program Registrations and Certifications for Critical Access Hospitals Modified 88 176 0 Form and Instruction 1 11 340B Registration Critical Access Hospitals (Orphan Drug)
340B Registration for all other covered entities Modified 606 606 0 Form and Instruction 1 5 340BRegistration-Covered Entities All Other Revised
Administrative Change Form Modified 2500 1250 0 Form and Instruction 1 9 NewChangeFormProposalPaperversion
Form and Instruction 1 Online version
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 7 STD Recert
Form and Instruction 2 7 TB Recert
Annual Recertification for Family Planning Modified 3879 1940 0 Form and Instruction 1 FP Recertification
Annual Recertification for Other Entities Modified 5681 2841 0 Form and Instruction 1 8 RW Recert
Certification to Enroll DSH and Children's Hospitals' Outpatient facilities to 340B Program Modified 606 303 0 Form and Instruction 1 3 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 1 Recert-Crtical Access; Sole-community; Rural-Referral centers (Orphan Drug)
Form and Instruction 1 Recert-Free standing (Orphan Drug)
Form and Instruction 1 4 Hospital Recertification
Form and Instruction 1 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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