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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.