340B Program Registrations & Certifications for Disproportionate Share Hospitals

340B Drug Pricing Program Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0327 can be found here:

Documents and Forms

Document Name Document Type
Form 340B-10b 340B Program Registrations & Certifications for Disproportionate Share Hospitals Form and Instruction
340b-10a Hospital Registration 340B Registration-DSH.doc Form and Instruction
340B-10b Certification of State/Local Contract Certif State Local Contract-DSH.doc Form and Instruction
340B-10c Certification of Non GPO Certif NonParticip by DSH in GPO.doc Form and Instruction

Information Collection (IC) Details

IC Title:	340B Program Registrations & Certifications for Disproportionate Share Hospitals	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	340B-10b	Certification of State/Local Contract	Certif State Local Contract-DSH.doc	Yes	No	Fillable Printable
Form and Instruction	340B-10c	Certification of Non GPO	Certif NonParticip by DSH in GPO.doc	Yes	No	Fillable Printable
Form and Instruction	340b-10a	Hospital Registration	340B Registration-DSH.doc	Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 70	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to New Statute	Previously Approved
Annual Number of Responses for this IC	1,606	1,536	70
Annual IC Time Burden (Hours)	402	384	18
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.