Information Collection

Pharmacy SOPS Database Data Use Agreement

IC 211068 under ICR 201702-0935-001 · OMB 0935-0218.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 Pharmacy SOPS Database Data Use Agreement	Form and Instruction
2 Attachment B: Pharmacy Database Data Use Agreement Attachment B - Pharmacy DUA - 02-22-2017_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	2	Attachment B: Pharmacy Database Data Use Agreement	Attachment B - Pharmacy DUA - 02-22-2017_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	100	-50	150
Annual IC Time Burden (Hours)	5	-3	8
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.