Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Contracted Pharmacy Services Registration and Recertifications Modified 37906 37906 0 Form 3.1 Contract Pharmacy Registration.pdf
Form 3.2 Contract Pharmacy Termination.pdf
Hospital Enrollment, Additions and Recertifcations Modified 30651 8977 0 Form 1.1 340B Registration DSH Parent.pdf
Form 1.2 340B Registration Children's Hospital.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 Childrens Hospital.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 and PPA Addendum Modified 200 200 0 Form and Instruction 6 Manufacturer PPA.pdf
Registrations and Recertifications for Entities other than Hospitals Modified 19153 6070 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
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: 109982 59359 0  
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