Information Collection

Submission of Administrative Changes for any Covered Entities

IC 190353 under ICR 202601-0915-001 · OMB 0915-0327.

Documents and Forms

Document Name Document Type
Form 4 340B Covered Entity Change Request.pdf Submission of Administrative Changes for any Covered Entities Form
4 340B Covered Entity Change Request.pdf 340B Participant Change Request.pdf Form
340B Participant Change Request Redline.pdf 340B Participant Change Request Redline 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 Participant 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: 24,829	Number of Respondents for Small Entity: 10,280

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	24,829	5,507	19,322
Annual IC Time Burden (Hours)	6,207	1,376	4,831
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
340B Participant Change Request Redline	340B Participant Change Request 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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