Annual Recertificaion for STD amp; TB

340B Drug Pricing Program Forms

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0327 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Annual Recertificaion for STD amp; TB Form and Instruction
1 7 STD Recert 7 STD Recert.pdf Form and Instruction
2 7 TB Recert 7 TB Recert.pdf Form and Instruction
Recertattestation.docx Recert Attestation IC Document

Information Collection (IC) Details

IC Title:	Annual Recertificaion for STD amp; TB	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	1	7 STD Recert	7 STD Recert.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	2	7 TB Recert	7 TB Recert.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,754	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	2,754	2,754
Annual IC Time Burden (Hours)	1,377	1,377
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Recert Attestation	Recertattestation.docx	08/27/2013

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