Information Collection

57.300 Hemovigilance Module Annual Survey -- Acute Care Facility

IC 190360 under ICR 201708-0920-029 · 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form CDC 57.300 57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Form
CDC 57.300 Hemovigilance Module - Annual Survey 57.300_HV Annual Facility Survey - Acute_BLANK.docx Form
Att G3_Biovigilance Component.pdf Att G3_Biovigilance Component IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	57.300 Hemovigilance Module Annual Survey -- Acute Care Facility	Agency IC Tracking Number:	0920-0666

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 - Acute_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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	500	0	500
Annual IC Time Burden (Hours)	1,000	0	1,000
Annual IC Cost Burden (Dollars)	34,990	1,850	33,140

Documents for IC

Title	Document	Date Uploaded
Att G3_Biovigilance Component	Att G3_Biovigilance Component.pdf	09/09/2015

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