Pharmacy Cost Form

Integrating Community Pharmacists and Clinical Sites for Patient-Centered HIV Care

Documents and Forms

Document Name Document Type
Pharmacy Cost Form Form
Pharmacy Cost Form Att 13 Pharmacy Cost Form.docx Form

Information Collection (IC) Details

IC Title:	Pharmacy Cost Form	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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Pharmacy Cost Form	Att 13 Pharmacy Cost Form.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 20	Number of Respondents for Small Entity: 0

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

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
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

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.