Submission of Administrative Changes for any Covered Entities

Enrollment and Re-Certification of Entities in the 340B Drug Pricing Program and Collection of Manufacturer Data to Verify 340B Drug Pricing Program Ceiling Price Calculations

Documents and Forms

Document Name Document Type
Form 4 Submission of Administrative Changes for any Covered Entities Form
4 340B Covered Entity Change Request.pdf 340B Participant Change Request.pdf Form
4 340B Covered Entity Change Request.pdf 340B Participant Change Request.pdf Form

Information Collection (IC) Details

IC Title:	Submission of Administrative Changes for any Covered 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	4	340B Covered Entity Change Request.pdf	340B Participant Change Request.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 19,322	Number of Respondents for Small Entity: 8,000

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

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	19,322	19,322
Annual IC Time Burden (Hours)	4,831	4,831
Annual IC Cost Burden (Dollars)	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.