57.300 Hemovigilance Module Annual Facility Survey

The National Healthcare Safety Network (NHSN)

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0666 can be found here:

Documents and Forms

Document Name Document Type
Form CDC 57.300 57.300 Hemovigilance Module Annual Facility Survey Form
CDC 57.300 Hemovigilance Module Annual Survey 57.300_HV Annual Facility Survey_BLANK.DOCX Form
Att G.2_ Biovigilance Component.pdf Att G.2_NHSN Biovigilance Component Hemovigilance Module Surveillance Protocol IC Document

Information Collection (IC) Details

IC Title:	57.300 Hemovigilance Module Annual Facility Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CDC 57.300	Hemovigilance Module Annual Survey	57.300_HV Annual Facility Survey_BLANK.DOCX		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 500	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	1,000	1,000
Annual IC Cost Burden (Dollars)	33,140	33,140

Documents for IC

Title	Document	Date Uploaded
Att G.2_NHSN Biovigilance Component Hemovigilance Module Surveillance Protocol	Att G.2_ Biovigilance Component.pdf	08/28/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.