Annual Recertificaion for STD & TB

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⚠️ Notice: This information collection may be referencing outdated material.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 1 Annual Recertificaion for STD & TB Form and Instruction
1 STD-Recert STD-Recert.pdf Form and Instruction
2 TB-Recertification TB-Recertification.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Annual Recertificaion for STD & TB	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

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	1	STD-Recert	STD-Recert.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	2	TB-Recertification	TB-Recertification.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,754	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	2,754	1,533	1,221
Annual IC Time Burden (Hours)	1,377	1,276	101
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.