340B Drug Pricing Program Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 340B Registration-CAH Revised	Form and Instruction	Modified	Available
Form 1 340B Registration Rural Referral Centers and Sole Community Hospitals (Orphan Drug)	Form and Instruction	Modified	Available
Form 1 340B Registration Rural Referral Centers and Sole Community Hospitals (Orphan Drug)	Form and Instruction	Modified	Available
Form 1 340B Registration Childrens and Free Standing Cance	Form and Instruction	Modified	Available
Form 1 340BManufacturerChangeForm Revised	Form and Instruction	Modified	Available
Form 1 Contract Pharmacy Registrationform Revised	Form and Instruction	Modified	Available
Form 1 340B Participatant Change Request Revised	Form and Instruction	Modified	Available
Form 1 RW-Recert	Form and Instruction	Modified	Available
Form 2 TB-Recertification	Form and Instruction	Modified	Available
Form 1 STD-Recert	Form and Instruction	Modified	Available
Form 1 FP-Recert	Form and Instruction	Modified	Available
Form 1 340BRegistration-Covered Entities All Other Revised	Form and Instruction	Modified	Available
Form 1 Recert-Free standing (Orphan Drug)	Form and Instruction	Modified	Available
Form 1 Recert-Crtical Access; Sole-community; Rural-Referral centers (Orphan Drug)	Form and Instruction	Modified	Available
Form 1b Recert Attestation	Form and Instruction	Modified	Available
Form 1a Hospital Recertification	Form and Instruction	Modified	Available
Form 1 340B Registration-Outpatient Facility Revised	Form and Instruction	Modified	Available
Form 2 GPO FOrm	Form and Instruction	Modified	Available
Form 4 Public OWNERSHIP Revised	Form and Instruction	Modified	Available
Form 3 Cert state or local government Revised	Form and Instruction	Modified	Available
Form 1 340B Registration Children's and Free Standing Cancer Hospitals revised	Form and Instruction	Modified	Available
Form 1 340B Registration DSH	Form and Instruction	Modified	Available
Form 4 Public OWNERSHIP Revised	Form and Instruction	Modified	Available
Form 2 Cert state or local government Revised	Form and Instruction	Modified	Available
Form 3 GPO Form	Form and Instruction	Modified	Available
OMB Form Changes Memo.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2013-07-19	Available
THE SUPPORTING STATEMENT.docx	Supporting Statement A	Uploaded 2013-07-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
203465	Pharmaceutical Pricing Agreement	Other-Program Agreement Form	Modified
203464	340B Program Registrations and Certifications for Critical Access Hospitals	Form and Instruction	Modified	340B Registration-CAH Revised
203463	340B Program Registrations amp; Certifications for Sole Community Hospitals	Form and Instruction	Modified	340B Registration Rural Referral Centers and Sole Community Hospitals (Orphan Drug)
203462	340B Program Registrations amp; Certifications for Rural Referral Hospitals	Form and Instruction	Modified	340B Registration Rural Referral Centers and Sole Community Hospitals (Orphan Drug)
203461	340B Program Registrations amp; Certifications for Free Standing Cancer Hospitals	Form and Instruction	Modified	340B Registration Childrens and Free Standing Cance
203460	Administrative Changes for Any Manufacturer	Form and Instruction	Modified	340BManufacturerChangeForm Revised
190354	Contract Pharmacy Self Certification Form	Form and Instruction	Modified	Contract Pharmacy Registrationform Revised
190353	Administrative Change Form	Form and Instruction	Modified	340B Participatant Change Request Revised
190352	Annual Recertification for Other Entities	Form and Instruction	Modified	RW-Recert
190351	Annual Recertificaion for STD amp; TB	Form and Instruction	Modified	TB-Recertification
190351	Annual Recertificaion for STD amp; TB	Form and Instruction	Modified	STD-Recert
190350	Annual Recertification for Family Planning	Form and Instruction	Modified	FP-Recert
190349	340B Registration for all other covered entities	Form and Instruction	Modified	340BRegistration-Covered Entities All Other Revised
190348	Hospital Annual Recertification	Form and Instruction	Modified	Recert-Free standing (Orphan Drug)
190348	Hospital Annual Recertification	Form and Instruction	Modified	Recert-Crtical Access; Sole-community; Rural-Referral centers (Orphan Drug)
190348	Hospital Annual Recertification	Form and Instruction	Modified	Recert Attestation
190348	Hospital Annual Recertification	Form and Instruction	Modified	Hospital Recertification
190347	Certification to Enroll DSH and Children's Hospitals' Outpatient facilities to 340B Program	Form and Instruction	Modified	340B Registration-Outpatient Facility Revised
190346	340B Program Registrations amp; Certifications for Children's Hospitals	Form and Instruction	Modified	GPO FOrm
190346	340B Program Registrations amp; Certifications for Children's Hospitals	Form and Instruction	Modified	Public OWNERSHIP Revised
190346	340B Program Registrations amp; Certifications for Children's Hospitals	Form and Instruction	Modified	Cert state or local government Revised
190346	340B Program Registrations amp; Certifications for Children's Hospitals	Form and Instruction	Modified	340B Registration Children's and Free Standing Cancer Hospitals revised
190345	340B Program Registrations amp; Certifications for Disproportionate Share Hospitals	Form and Instruction	Modified	340B Registration DSH
190345	340B Program Registrations amp; Certifications for Disproportionate Share Hospitals	Form and Instruction	Modified	Public OWNERSHIP Revised
190345	340B Program Registrations amp; Certifications for Disproportionate Share Hospitals	Form and Instruction	Modified	Cert state or local government Revised
190345	340B Program Registrations amp; Certifications for Disproportionate Share Hospitals	Form and Instruction	Modified	GPO Form

ICR Details

OMB Control No: 0915-0327	ICR Reference No: 201307-0915-006
Status: Historical Active	Previous ICR Reference No: 201304-0915-004
Agency/Subagency: HHS/HSA	Agency Tracking No: 20086
Title: 340B Drug Pricing Program Forms
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/23/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/22/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2015	10/31/2015	10/31/2015
Responses	24,464	0	24,464
Time Burden (Hours)	14,705	0	14,705
Cost Burden (Dollars)	0	0	0

---

Abstract: HRSA Office of Pharmacy Affairs (OPA) has a process for registering covered entities who choose to participate in the section 340B Drug Pricing Program. These entities must comply with the requirements of 340B (a)(5)(A) of the PHS Act. The 340B Drug Pricing Program forms allow entities to provide registration and certifying information and to determine eligibility for the progam.

---

Authorizing Statute(s): PL: Pub.L. 102 - 585 601-603 Name of Law: Veterans Health Care Act of 1992
   US Code: 42 USC 340B Name of Law: Public Health Service Act
   PL: Pub.L. 111 - 148 7101 Name of Law: Patient Protection and Affordable Care Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 16

table that charts list of burden

IC Title	Form No.	Form Name
340B Program Registrations amp; Certifications for Children's Hospitals	1, 3, 4, 2	340B Registration Children's and Free Standing Cancer Hospitals revised ,   Cert state or local government Revised ,   Public OWNERSHIP Revised ,   GPO FOrm
340B Program Registrations amp; Certifications for Disproportionate Share Hospitals	3, 2, 4, 1	GPO Form ,   Cert state or local government Revised ,   Public OWNERSHIP Revised ,   340B Registration DSH
340B Program Registrations amp; Certifications for Free Standing Cancer Hospitals	1	340B Registration Childrens and Free Standing Cance
340B Program Registrations amp; Certifications for Rural Referral Hospitals	1	340B Registration Rural Referral Centers and Sole Community Hospitals (Orphan Drug)
340B Program Registrations amp; Certifications for Sole Community Hospitals	1	340B Registration Rural Referral Centers and Sole Community Hospitals (Orphan Drug)
340B Program Registrations and Certifications for Critical Access Hospitals	1	340B Registration-CAH Revised
340B Registration for all other covered entities	1	340BRegistration-Covered Entities All Other Revised
Administrative Change Form	1	340B Participatant Change Request Revised
Administrative Changes for Any Manufacturer	1	340BManufacturerChangeForm Revised
Annual Recertificaion for STD amp; TB	1, 2	STD-Recert ,   TB-Recertification
Annual Recertification for Family Planning	1	FP-Recert
Annual Recertification for Other Entities	1	RW-Recert
Certification to Enroll DSH and Children's Hospitals' Outpatient facilities to 340B Program	1	340B Registration-Outpatient Facility Revised
Contract Pharmacy Self Certification Form	1	Contract Pharmacy Registrationform Revised
Hospital Annual Recertification	1a, 1b, 1, 1	Hospital Recertification ,   Recert Attestation ,   Recert-Crtical Access; Sole-community; Rural-Referral centers (Orphan Drug) ,   Recert-Free standing (Orphan Drug)
Pharmaceutical Pricing Agreement

---

ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	24,464	24,464	0	0	0	0
Annual Time Burden (Hours)	14,705	14,705	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $101,004

Does this IC contain surveys, censuses, or employ statistical methods? No

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Yes

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 07/22/2013

---