Form No number No number Monthly reporting plan

OMB No. 0920-0666

EXP. Date: XX-XX-XXXX

Hemovigilance Module

Monthly Reporting Plan

Facility ID#: _______________ Month __ __/ Year ___ ___ ___ ___

All reporting is facility-wide.

Adverse transfusion reactions & all incidents associated with reactions

Monthly reporting denominators

Incidents reporting – summary data with detailed reporting of high priority incidents

OR

Incidents reporting – detailed reports of all incidents

Assurance of Confidentiality: The information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)).

Public reporting burden of this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333 ATTN: PRA (0920-0666).

CDC 57.301