Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Contracted Pharmacy Services Registration and Recertifications Modified 48136 48136 0 Form 3.1 Contract Pharmacy Registration.pdf
Form 3.2 Contract Pharmacy Termination.pdf
Hospital Enrollment, Additions and Recertifcations Modified 41475 12224 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 73 73 0 Form 6 Manufacturer PPA.pdf
Registrations and Recertifications for Entities other than Hospitals Modified 24267 7372 0 Form 2.1 340B Registration CHC and FQHCLA.pdf
Form 2.2 340B Registration STD and TB.pdf
Form 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 471 236 0 Form 5 340B Manufacturer Change Form.pdf
Submission of Administrative Changes for any Covered Entities Modified 24829 6207 0 Form 4 340B Covered Entity Change Request.pdf
Total burden requested under this ICR: 141651 75448 0  
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