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⚠️ Notice: This information collection may be referencing outdated material.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

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

Information Collection (IC) Details

View Information Collection (IC)

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:

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 %

	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

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.