Information Collection

Hospital Enrollment, Additions and Recertifcations

IC 190345 under ICR 202601-0915-001 · OMB 0915-0327.

Documents and Forms

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.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 Childrens Hospital.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.pdf 340B Registration Children's Hospital.pdf Form
1.3 340B Registration CAN Parent.pdf 340B Registration Free Standing Cancer.pdf Form
1.4 340B Registration Hospital Outpatient Facility.pdf 340B Registration- Outpatient Facility.pdf Form
1.5 340B Registration RRC and SCH Parent.pdf 340B Registration Rural Referral and Sole Community Hospitals.pdf Form
1.6 340B Registration CAH Parent.pdf 340B Registration-CAH.pdf Form
1.7 340B Recertification DSH.pdf 340B Recertification DSH.pdf Form
1.8 340B Recertification SCH and RRC.pdf 340B Recertification Sole-community; Rural-Referral centers.pdf Form
1.9 340B Recertification Childrens Hospital.pdf 340B Recertification Children's Hospital.pdf Form
1.10 340B Recertification CAH.pdf 340B Recertification-CAH.pdf Form
1.11 340B Recertification CAN.pdf 340B Recertification Free Standing Cancer.pdf Form
340B Registration Children's Hospital Redline.pdf 340B Registration Children's Hospital Redline IC Document
340B Registration DSH Parent Redline.pdf 340B Registration DSH Parent Redline IC Document
340B Registration Free Standing Cancer Redline.pdf 340B Registration Free Standing Cancer Redline IC Document
340B Registration- Outpatient Facility Redline.pdf 340B Registration- Outpatient Facility Redline IC Document
340B Registration Rural Referral and Sole Community Hospitals Redline.pdf 340B Registration Rural Referral and Sole Community Hospitals Redline IC Document
340B Registration-CAH Redline.pdf 340B Registration-CAH Redline 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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1.1	340B Registration DSH Parent.pdf	340B Registration DSH Parent.pdf	Yes	Yes	Fillable Fileable
Form	1.2	340B Registration Children's Hospital.pdf	340B Registration Children's Hospital.pdf	Yes	Yes	Fillable Fileable
Form	1.3	340B Registration CAN Parent.pdf	340B Registration Free Standing Cancer.pdf	Yes	Yes	Fillable Fileable
Form	1.4	340B Registration Hospital Outpatient Facility.pdf	340B Registration- Outpatient Facility.pdf	Yes	Yes	Fillable Fileable
Form	1.5	340B Registration RRC and SCH Parent.pdf	340B Registration Rural Referral and Sole Community Hospitals.pdf	Yes	Yes	Fillable Fileable
Form	1.6	340B Registration CAH Parent.pdf	340B Registration-CAH.pdf	Yes	Yes	Fillable Fileable
Form	1.7	340B Recertification DSH.pdf	340B Recertification DSH.pdf	Yes	Yes	Fillable Fileable
Form	1.8	340B Recertification SCH and RRC.pdf	340B Recertification Sole-community; Rural-Referral centers.pdf	Yes	Yes	Fillable Fileable
Form	1.9	340B Recertification Childrens Hospital.pdf	340B Recertification Children's Hospital.pdf	Yes	Yes	Fillable Fileable
Form	1.10	340B Recertification CAH.pdf	340B Recertification-CAH.pdf	Yes	Yes	Fillable Fileable
Form	1.11	340B Recertification CAN.pdf	340B Recertification Free Standing Cancer.pdf	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: 3,907	Number of Respondents for Small Entity: 17

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

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	41,475	10,824	30,651
Annual IC Time Burden (Hours)	12,224	3,247	8,977
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
340B Registration Children's Hospital Redline	340B Registration Children's Hospital Redline.pdf	01/08/2026
340B Registration DSH Parent Redline	340B Registration DSH Parent Redline.pdf	01/08/2026
340B Registration Free Standing Cancer Redline	340B Registration Free Standing Cancer Redline.pdf	01/08/2026
340B Registration- Outpatient Facility Redline	340B Registration- Outpatient Facility Redline.pdf	01/08/2026
340B Registration Rural Referral and Sole Community Hospitals Redline	340B Registration Rural Referral and Sole Community Hospitals Redline.pdf	01/08/2026
340B Registration-CAH Redline	340B Registration-CAH Redline.pdf	01/08/2026

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

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