Information Collection

Contract Pharmacy Registration Form

IC 190354 under ICR 201604-0915-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Contract Pharmacy Registration Form	Form
1 Contract Pharmacy Registration-Revised Contract Pharmacy Registration-Revised.pdf	Form
2 Contract Pharmacy Termination Contract Pharmacy Termination.pdf	Form

IC Title:

Contract Pharmacy Registration Form

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	1	Contract Pharmacy Registration-Revised	Contract Pharmacy Registration-Revised.pdf		Yes	Yes	Fillable Fileable
Form	2	Contract Pharmacy Termination	Contract Pharmacy Termination.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,758

Number of Respondents for Small Entity: 1,200

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	8,790	8,790
Annual IC Time Burden (Hours)	8,790	8,790
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.