Survey of Retail Community Pharmacy Invoice Prices

Survey of Retail Prices: Payment and Utilization Rates, and Performance Rankings (CMS-10241)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0938-1041 can be found here:

Documents and Forms

Document Name Document Type
Dear Pharmacy Owner Letter 12-2014 CLEAN.PDF Instruction
Survey Cover Sheet 12-2014.pdf Other-Cover Sheet
1 NADAC Survey Tool NADAC Survey Tool 12-2014 CLEAN.PDF Form and Instruction

Information Collection (IC) Details

IC Title:	Survey of Retail Community Pharmacy Invoice Prices	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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction			Dear Pharmacy Owner Letter 12-2014 CLEAN.PDF	Yes	No	Fillable Printable
Other-Cover Sheet			Survey Cover Sheet 12-2014.pdf	Yes	No	Fillable Printable
Form and Instruction	1	NADAC Survey Tool	NADAC Survey Tool 12-2014 CLEAN.PDF	Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 30,000	Number of Respondents for Small Entity: 8,760

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 70 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30,000	30,000
Annual IC Time Burden (Hours)	15,000	15,000
Annual IC Cost Burden (Dollars)	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.