Information Collection

57.304 Hemovigilance Module Adverse Reaction

IC 190365 under ICR 201407-0920-007 · OMB 0920-0666.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form CDC 57.304 57.304 Hemovigilance Module Adverse Reaction	Form
CDC 57.304 Hemovigilance Adverse Reaction 57.304_HV Adverse Reaction_BLANK.DOCX	Form
Att G.2_ Biovigilance Component.pdf Att G.2_NHSN Biovigilance Component: Hemovigilance Module Surveillance Protocol	IC Document

IC Title:

57.304 Hemovigilance Module Adverse Reaction

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	CDC 57.304	Hemovigilance Adverse Reaction	57.304_HV Adverse Reaction_BLANK.DOCX		Yes	Yes	Fillable Fileable

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: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	24,000	24,000
Annual IC Time Burden (Hours)	6,000	6,000
Annual IC Cost Burden (Dollars)	198,840	198,840

Documents for IC

table that charts IC Documents
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.