340B Program Registrations amp; Certifications for Disproportionate Share Hospitals

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⚠️ Notice: This information collection may be referencing outdated material.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 340B Program Registrations amp; Certifications for Disproportionate Share Hospitals Form
1 340B Registration DSH-Revised 340B Registration DSH-Revised.docx Form
3 Public Ownership-Revised Public Ownership-Revised.docx Form
2 Cert state or local government-Revised.docx Cert state or local government-Revised.docx Form

Information Collection (IC) Details

IC Title:	340B Program Registrations amp; Certifications for Disproportionate Share Hospitals	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	340B Registration DSH-Revised	340B Registration DSH-Revised.docx	Yes	Yes	Fillable Fileable
Form	3	Public Ownership-Revised	Public Ownership-Revised.docx	Yes	Yes	Fillable Fileable
Form	2	Cert state or local government-Revised.docx	Cert state or local government-Revised.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 44	Number of Respondents for Small Entity: 44

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	44	-286	330
Annual IC Time Burden (Hours)	88	-572	660
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.