Information Collection

Submission of Administrative Changes for any Covered Entities

IC 190353 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 4 Submission of Administrative Changes for any Covered Entities Form
4 340B Covered Entity Change Request.pdf 340B Covered Entity Change Request..pdf Form
340B Participant Change Request.docx REDLINE Covered Entity Change Request IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Submission of Administrative Changes for any Covered Entities	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	4	340B Covered Entity Change Request.pdf	340B Covered Entity Change Request..pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 19,322	Number of Respondents for Small Entity: 8,000

Affected Public: Private Sector	Private Sector: Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	19,322	9,926	9,396
Annual IC Time Burden (Hours)	4,831	133	4,698
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
REDLINE Covered Entity Change Request	340B Participant Change Request.docx	08/12/2019

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