Certification to Enroll DSH and Children's Hospitals' Outpatient facilities to 340B Program

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⚠️ Notice: This information collection may be referencing outdated material.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-3a Certification to Enroll DSH and Children's Hospitals' Outpatient facilities to 340B Program Form and Instruction
340B-3a DSH Outpatient Form 340B Registration- DSH Outpt facilities.doc Form and Instruction
340B -3b Children's Hospital Outpatient Form 340B Registration- Childrens Hospital Outpt facilities.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Certification to Enroll DSH and Children's Hospitals' Outpatient facilities to 340B Program	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	340B-3a	DSH Outpatient Form	340B Registration- DSH Outpt facilities.doc		Yes	No	Fillable Printable
Form and Instruction	340B -3b	Children's Hospital Outpatient Form	340B Registration- Childrens Hospital Outpt facilities.doc		Yes	No	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 180	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	2,039	1,859	180
Annual IC Time Burden (Hours)	169	154	15
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.