Information Collection

Hospital Enrollment, Additions and Recertifcations

IC 190345 under ICR 201908-0915-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 1.1 340B Registration DSH Parent.pdf Hospital Enrollment, Additions and Recertifcations	Form
Form 1.2 340B Registration Children's Hospital PED Parent.pdf Hospital Enrollment, Additions and Recertifcations	Form
Form 1.3 340B Registration CAN Parent.pdf Hospital Enrollment, Additions and Recertifcations	Form
Form 1.4 340B Registration Hospital Outpatient Facility.pdf Hospital Enrollment, Additions and Recertifcations	Form
Form 1.5 340B Registration RRC and SCH Parent.pdf Hospital Enrollment, Additions and Recertifcations	Form
Form 1.6 340B Registration CAH Parent.pdf Hospital Enrollment, Additions and Recertifcations	Form
Form 1.7 340B Recertification DSH.pdf Hospital Enrollment, Additions and Recertifcations	Form
Form 1.8 340B Recertification SCH and RRC.pdf Hospital Enrollment, Additions and Recertifcations	Form
Form 1.9 340B Recertification PED.pdf Hospital Enrollment, Additions and Recertifcations	Form
Form 1.10 340B Recertification CAH.pdf Hospital Enrollment, Additions and Recertifcations	Form
Form 1.11 340B Recertification CAN.pdf Hospital Enrollment, Additions and Recertifcations	Form
1.1 340B Registration DSH Parent.pdf 340B Registration DSH Parent..pdf	Form
1.2 340B Registration Children's Hospital PED Parent.pdf 340B Registration PED Parent..pdf	Form
1.3 340B Registration CAN Parent.pdf 340B Registration CAN Parent..pdf	Form
1.4 340B Registration Hospital Outpatient Facility.pdf 340B Registration Hospital Outpatient Facility..pdf	Form
1.5 340B Registration RRC and SCH Parent.pdf 340B Registration RRC and SCH Parent..pdf	Form
1.6 340B Registration CAH Parent.pdf 340B Registration CAH Parent..pdf	Form
1.7 340B Recertification DSH.pdf 340B Recertification DSH..pdf	Form
1.8 340B Recertification SCH and RRC.pdf 340B Recertification SCH and RRC.pdf	Form
1.9 340B Recertification PED.pdf 340B Recertification PED..pdf	Form
1.10 340B Recertification CAH.pdf 340B Recertification CAH..pdf	Form
1.11 340B Recertification CAN.pdf 340B Recertification CAN.pdf	Form
340B Registration DSH.docx Registration DSH	IC Document
340B Registration Children's Hospital.docx Registration PED	IC Document
340B Registration Free Standing Cancer Hospital.docx Registration CAN	IC Document
340B Registration Outpatient.docx Registration Outpatient	IC Document
340B Registration SCH and RRC.docx Registration SCH and RRC	IC Document
340B Registration CAH.docx REDLINE Registration CAH	IC Document
Recert DSH.docx REDLINE Recert DSH	IC Document
Recert RRC and SCH.docx REDLINE Recert SCH and RRC	IC Document
Recert Childrens PED.docx REDLINE Recert PED	IC Document
Recert CAH.docx REDLINE Recert CAH	IC Document
Recert CAN.docx REDLINE Recert CAN	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Hospital Enrollment, Additions and Recertifcations

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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1.1	Yes	Yes	Fillable Fileable
Form	1.2	Yes	Yes	Fillable Fileable
Form	1.3	Yes	Yes	Fillable Fileable
Form	1.4	Yes	Yes	Fillable Fileable
Form	1.5	Yes	Yes	Fillable Fileable
Form	1.6	Yes	Yes	Fillable Fileable
Form	1.7	Yes	Yes	Fillable Fileable
Form	1.8	Yes	Yes	Fillable Fileable
Form	1.9	Yes	Yes	Fillable Fileable
Form	1.10	Yes	Yes	Fillable Fileable
Form	1.11	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 3,394

Number of Respondents for Small Entity: 15

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	30,378	30,184	194
Annual IC Time Burden (Hours)	9,358	8,970	388
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Registration DSH		08/12/2019
Registration PED		08/12/2019
Registration CAN		08/12/2019
Registration Outpatient		08/12/2019
Registration SCH and RRC		08/12/2019
REDLINE Registration CAH		08/12/2019
REDLINE Recert DSH		08/12/2019
REDLINE Recert SCH and RRC		08/12/2019
REDLINE Recert PED		08/12/2019
REDLINE Recert CAH		08/12/2019
REDLINE Recert CAN		08/12/2019

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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