Information Collection

Pharmacy Cost Form

IC 216729 under ICR 201505-0920-005 · OMB 0920-1019.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1019 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Pharmacy Cost Form	Form
Revised Pharmacy Cost Form Att 13_Pharmacy Cost Form_OMB comments_KB_clean copy.docx	Form

IC Title:

Pharmacy Cost Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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	none	Revised Pharmacy Cost Form	Att 13_Pharmacy Cost Form_OMB comments_KB_clean copy.docx		No		Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 20

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	40	40
Annual IC Time Burden (Hours)	400	400
Annual IC Cost Burden (Dollars)	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.