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 340B Registration Children's Hospital -Revised
Form 2 Cert state or local government-Revised
Form 3 Public Ownership-Revised.docx
340B Program Registrations amp; Certifications for Disproportionate Share Hospitals Modified 44 88 0 Form 1 340B Registration DSH-Revised
Form 3 Public Ownership-Revised
Form 2 Cert state or local government-Revised.docx
340B Program Registrations amp; Certifications for Free Standing Cancer Hospitals Modified 30 60 0 Form 1 340B Registration Free Standing Cancer-Revised
340B Program Registrations amp; Certifications for Rural Referral Hospitals Modified 30 60 0 Form 1 340B Registration Rural Referral and Sole Community Hospitals (Orphan Drug)-REVISED
340B Program Registrations amp; Certifications for Sole Community Hospitals Modified 30 60 0 Form 1 340B Registration Rural Referral and Sole Community Hospitals (Orphan Drug)-REVISED
340B Program Registrations and Certifications for Critical Access Hospitals Modified 30 60 0 Form 1 340B Registration-CAH-Revised
340B Registration for all other covered entities Modified 2958 2958 0 Form and Instruction 1 340BRegistration-Covered Entities - Community Health Center
Form and Instruction 2 340BRegistration-Covered Entities All Other-Revised
Form and Instruction 3 340BRegistration-Covered Entities STD-Revised
Form and Instruction 4 340BRegistration-Covered Entities TB-Revised
Administrative Change Form Modified 9396 4698 0 Form and Instruction 1 340B Participant Change Request-Revised
Administrative Changes for Any Manufacturer Modified 350 175 0 Form 1 340B Manufacturer Change Form-Revised
Annual Recertificaion for STD amp; TB Modified 3123 781 0 Form 1 STD-Recertification
Form 2 TB-Recertification
Annual Recertification for Family Planning Modified 3629 907 0 Form 1 FP-Recert
Annual Recertification for Other Entities Modified 2474 619 0 Form 2 RW-Recertification-Revised
Form and Instruction 1 Conmmunity Health Center Recert
Certification to Enroll DSH and Children's Hospitals' Outpatient facilities to 340B Program Modified 6273 3137 0 Form and Instruction 1 3 340B Registration-Outpatient Facility Revised
Contract Pharmacy Self Certification Form Modified 8790 8790 0 Form 1 Contract Pharmacy Registration-Revised
Form 2 Contract Pharmacy Termination
Hospital Annual Recertification Modified 12804 3201 0 Form 2 Recert-Critical Access; Sole-community; Rural-Referral centers (Orphan Drug)-Revised
Form 1 Public Ownership-Revised.docx
Form 3 Recert-Free standing Cancer Hospital (Orphan Drug)-Revised.pdf
Manufacturer Data Required to Verify 340 B Ceiling Price Calculations New 2400 1200 0 Form 1 Manufacturer Data Fields for 340B Ceiling Price - FINAL VERSION
Pharmaceutical Pricing Agreement Modified 200 200 0 Form and Instruction 1 Manufacturer Pharma Pricing Agreement (PPA)
Total burden requested under this ICR: 52591 27054 0  
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