Notice to Treat up to 275 Patients

Notification of Intent to Use Schedule III, IV, or V Opioid Drugs for the Maintenance and Detoxification Treatment of Opiate Addiction

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0234 can be found here:

Documents and Forms

Document Name Document Type
Form Waiver Form 275 pa Notice to Treat up to 275 Patients Form and Instruction
Waiver Form 275 pa Waiver Form 275 patients Attachment C NOI 275 Waiver 9.16.19.doc Form and Instruction

Information Collection (IC) Details

IC Title:	Notice to Treat up to 275 Patients	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Waiver Form 275 patients	Waiver Form 275 patients	Attachment C NOI 275 Waiver 9.16.19.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 800	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	800	283	517
Annual IC Time Burden (Hours)	65	-194	259
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.