Information Collection

Certification to Enroll DSH and Children's Hospitals' Outpatient facilities to 340B Program

IC 190347 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⚠️ Notice: This information collection may be referencing outdated material.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 Certification to Enroll DSH and Children's Hospitals' Outpatient facilities to 340B Program	Form and Instruction
1 3 340B Registration-Outpatient Facility Revised 3 340B Registration-Outpatient Facility Revised.docx	Form and Instruction

IC Title:

Certification to Enroll DSH and Children's Hospitals' Outpatient facilities to 340B Program

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	3 340B Registration-Outpatient Facility Revised	3 340B Registration-Outpatient Facility 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: 697

Number of Respondents for Small Entity: 15

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

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	6,273	5,667	606
Annual IC Time Burden (Hours)	3,137	2,834	303
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.