Information Collection

Pharmacy Background Characteristics Form

IC 211067 under ICR 201702-0935-001 · OMB 0935-0218.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 3 Pharmacy Background Characteristics Form	Form and Instruction
3 Attachment C: Pharmacy Site Information Form Attachment C - Pharmacy Site Information Form_updated 6-13-17_clean.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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 and Instruction	3	Attachment C: Pharmacy Site Information Form	Attachment C - Pharmacy Site Information Form_updated 6-13-17_clean.docx		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	300	-1,200	1,500
Annual IC Time Burden (Hours)	25	-100	125
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.