Information Collection

Submission of Administrative Changes for any Covered Entities

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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

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				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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
340B Participant Change Request Redline		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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