Annual Recertification for Other Entities

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⚠️ Notice: This information collection may be referencing outdated material.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 2 Annual Recertification for Other Entities Form
2 RW-Recertification-Revised RW-Recertification-Revised.pdf Form
1 Conmmunity Health Center Recert Conmmunity Health Center Recert.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Annual Recertification for Other Entities	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	2	RW-Recertification-Revised	RW-Recertification-Revised.pdf		Yes	Yes	Fillable Fileable
Form and Instruction	1	Conmmunity Health Center Recert	Conmmunity Health Center 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: 2,474	Number of Respondents for Small Entity: 730

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	2,474	-3,207	5,681
Annual IC Time Burden (Hours)	619	-2,222	2,841
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.