340B Program Registrations amp; Certifications for Disproportionate Share Hospitals

340B Drug Pricing Program Forms

OMB: 0915-0327

IC ID: 190345

Information Collection (IC) Details

View Information Collection (IC)

340B Program Registrations amp; Certifications for Disproportionate Share Hospitals
 
No Modified
 
Required to Obtain or Retain Benefits
 

Document Type Form No. Form Name Instrument File URL 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

Health Health Care Services

 

44 44
   
State, Local, and Tribal Governments
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 44 0 -286 0 0 330
Annual IC Time Burden (Hours) 88 0 -572 0 0 660
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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