Hospital Annual Recertification

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⚠️ Notice: This information collection may be referencing outdated material.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 Hospital Annual Recertification Form
2 Recert-Critical Access; Sole-community; Rural-Referral c Recert-Critical Access; Sole-community; Rural-Referral centers (Orphan Drug)-Revised.pdf Form
1 Public Ownership-Revised.docx Hospital Recertification-DSH.pdf Form
3 Recert-Free standing Cancer Hospital (Orphan Drug)-Revis Recert-Free standing Cancer Hospital (Orphan Drug)-Revised.pdf Form

Information Collection (IC) Details

IC Title:	Hospital Annual Recertification	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	Public Ownership-Revised.docx	Hospital Recertification-DSH.pdf	Yes	Yes	Fillable Fileable
Form	3	Recert-Free standing Cancer Hospital (Orphan Drug)-Revised.pdf	Recert-Free standing Cancer Hospital (Orphan Drug)-Revised.pdf	Yes	Yes	Fillable Fileable
Form	2	Recert-Critical Access; Sole-community; Rural-Referral centers (Orphan Drug)-Revised	Recert-Critical Access; Sole-community; Rural-Referral centers (Orphan Drug)-Revised.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,134	Number of Respondents for Small Entity: 280

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	12,804	7,962	4,842
Annual IC Time Burden (Hours)	3,201	780	2,421
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.