Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
340B Registration for all other covered entities Removed 0 0 0 Form and Instruction 1 340BRegistration-Covered Entities All Other-Revised
Annual Recertificaion for STD amp; TB Removed 0 0 0 Form 1 STD-Recertification
Form 2 TB-Recertification
Annual Recertification for Community Health Centers Removed 0 0 0 Form 1 Conmmunity Health Center Recert
Annual Recertification for Other Entities Removed 0 0 0 Form 2 RW-Recertification-Revised
Contract Pharmacy Registration Form Removed 0 0 0 Form 1 Contract Pharmacy Registration-Revised
Form 2 Contract Pharmacy Termination
Contracted Pharmacy Services Registration and Recertifications Modified 22528 22528 0 Form 3.1 Contract Pharmacy Registration.pdf
Form 3.2 Contract Pharmacy Termination.pdf
Hospital Enrollment, Additions and Recertifcations Modified 30378 9358 0 Form 1.1 340B Registration DSH Parent.pdf
Form 1.2 340B Registration Children's Hospital PED Parent.pdf
Form 1.3 340B Registration CAN Parent.pdf
Form 1.4 340B Registration Hospital Outpatient Facility.pdf
Form 1.5 340B Registration RRC and SCH Parent.pdf
Form 1.6 340B Registration CAH Parent.pdf
Form 1.7 340B Recertification DSH.pdf
Form 1.8 340B Recertification SCH and RRC.pdf
Form 1.9 340B Recertification PED.pdf
Form 1.10 340B Recertification CAH.pdf
Form 1.11 340B Recertification CAN.pdf
Manufacturer Data Required to Verify 340 B Ceiling Price Modified 2400 1200 0 Form 7 Manufacturer Data Fields for 340B Ceiling Price.pdf
Pharmaceutical Pricing Agreement Removed 0 0 0 Form and Instruction 1 Manufacturer Pharma Pricing Agreement (PPA)
Pharmaceutical Pricing Agreement and PPA Addendum Modified 200 200 0 Form and Instruction 6 Manufacturer PPA and addendum.pdf
Registrations and Recertifications for Entities other than Hospitals Modified 19451 6368 0 Form and Instruction 2.1 340B Registration CHC and FQHCLA.pdf
Form and Instruction 2.2 340B Registration STD and TB.pdf
Form and Instruction 2.3 340B Registration-Covered Entities All Other Non-Hospitals.pdf
Form 2.4 340B Recertfication STD and TB.pdf
Form 2.5 340B Recertification CHC and FQHCLA.pdf
Form 2.6 340B Recertification Covered Entities All Other Non-Hospital..pdf
Registrations for Community Health Centers Removed 0 0 0 Form and Instruction 1 340BRegistration-Covered Entities - Community Health Center.docx
Registrations for STD/TB Clinics Removed 0 0 0 Form and Instruction 1 340BRegistration-Covered Entities STD-Revised
Form and Instruction 2 340BRegistration-Covered Entities TB-Revised
Submission of Administrative Changes for Any Manufacturer Modified 350 175 0 Form and Instruction 5 340B Manufacturer Change Form.pdf
Submission of Administrative Changes for any Covered Entities Modified 19322 4831 0 Form 4 340B Covered Entity Change Request.pdf
Total burden requested under this ICR: 94629 44660 0  
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