Information Collection

340B Program Registrations amp; Certifications for Disproportionate Share Hospitals

IC 190345 under ICR 201504-0915-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 amp; Certifications for Disproportionate Share Hospitals	Form
1 340B Registration DSH-Revised 340B Registration DSH-Revised.docx	Form
3 Public Ownership-Revised Public Ownership-Revised.docx	Form
2 Cert state or local government-Revised.docx Cert state or local government-Revised.docx	Form

IC Title:

340B Program Registrations amp; 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	1	340B Registration DSH-Revised	340B Registration DSH-Revised.docx	Yes	Yes	Fillable Fileable
Form	3	Public Ownership-Revised	Public Ownership-Revised.docx	Yes	Yes	Fillable Fileable
Form	2	Cert state or local government-Revised.docx	Cert state or local government-Revised.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 44

Number of Respondents for Small Entity: 44

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	44	-286	330
Annual IC Time Burden (Hours)	88	-572	660
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.