Information Collection

57.317_hv Ar-trali_blan

IC 222904 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⚠️ Notice: This information collection may be referencing outdated material.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

Documents and forms in this information collection
Document Name	Document Type
Form 57.317 57.317_HV AR-TRALI_BLAN	Form
57.317 Hemovigilance Adverse Reaction - Transfusion Related Acu 57.317_HV AR-TRALI_BLANK.DOCX	Form

IC Title:

57.317_HV AR-TRALI_BLAN

Agency IC Tracking Number:

0920-0666

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	57.317	Hemovigilance Adverse Reaction - Transfusion Related Acute Lung Injury	57.317_HV AR-TRALI_BLANK.DOCX		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

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

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	500	0	500
Annual IC Time Burden (Hours)	167	-41	208
Annual IC Cost Burden (Dollars)	5,832	5,832	0

Documents for IC

table that charts IC Documents
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.