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 30 60 0 Form 1
Form 2
Form 3
340B Program Registrations amp; Certifications for Disproportionate Share Hospitals Modified 44 88 0 Form 1
Form 3
Form 2
340B Program Registrations amp; Certifications for Free Standing Cancer Hospitals Modified 30 60 0 Form 1
340B Program Registrations amp; Certifications for Rural Referral Hospitals Modified 30 60 0 Form 1
340B Program Registrations amp; Certifications for Sole Community Hospitals Modified 30 60 0 Form 1
340B Program Registrations and Certifications for Critical Access Hospitals Modified 30 60 0 Form 1
340B Registration for all other covered entities Modified 2958 2958 0 Form and Instruction 1
Form and Instruction 2
Form and Instruction 3
Form and Instruction 4
Administrative Change Form Modified 9396 4698 0 Form and Instruction 1
Administrative Changes for Any Manufacturer Modified 350 175 0 Form 1
Annual Recertificaion for STD amp; TB Modified 3123 781 0 Form 1
Form 2
Annual Recertification for Family Planning Modified 3629 907 0 Form 1
Annual Recertification for Other Entities Modified 2474 619 0 Form 2
Form and Instruction 1
Certification to Enroll DSH and Children's Hospitals' Outpatient facilities to 340B Program Modified 6273 3137 0 Form and Instruction 1
Contract Pharmacy Self Certification Form Modified 8790 8790 0 Form 1
Form 2
Hospital Annual Recertification Modified 12804 3201 0 Form 2
Form 1
Form 3
Manufacturer Data Required to Verify 340 B Ceiling Price Calculations New 2400 1200 0 Form 1
Pharmaceutical Pricing Agreement Modified 200 200 0 Form and Instruction 1
Total burden requested under this ICR: 52591 27054 0  
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