Information Collection

340B Program Registrations & Certifications for Disproportionate Share Hospitals

IC 190345 under ICR 201006-0915-003 · OMB 0915-0327.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.