Information Collection

340B Program Registrations & Certifications for Disproportionate Share Hospitals

IC 190345 under ICR 201207-0915-003 · 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⚠️ Notice: This information collection may be referencing outdated material.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 1 340B Program Registrations & Certifications for Disproportionate Share Hospitals	Form and Instruction
1 340B Registration-DSH Revised 340B Registration-DSH Revised.pdf	Form and Instruction
3 GPOform Revised GPOform Revised.pdf	Form and Instruction
2 Cert state or local government Revised Cert state or local government Revised.pdf	Form and Instruction
4 Public OWNERSHIP Revised Public OWNERSHIP Revised.pdf	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	1	340B Registration-DSH Revised	340B Registration-DSH Revised.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	3	GPOform Revised	GPOform Revised.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	2	Cert state or local government Revised	Cert state or local government Revised.pdf	Yes	Yes	Fillable Fileable
Form and Instruction	4	Public OWNERSHIP Revised	Public OWNERSHIP Revised.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 330

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	330	-1,276	1,606
Annual IC Time Burden (Hours)	660	258	402
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.