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⚠️ Notice: This information collection may be referencing outdated material.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
1 STD-Recertification STD-Recertification.pdf Form
2 TB-Recertification TB-Recertification.pdf Form

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: 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	1	STD-Recertification	STD-Recertification.pdf		Yes	Yes	Fillable Fileable
Form	2	TB-Recertification	TB-Recertification.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,123	Number of Respondents for Small Entity: 940

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	3,123	369	2,754
Annual IC Time Burden (Hours)	781	-596	1,377
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.