Information Collection

57.310_hv Ar-dstr_blank

IC 222897 under ICR 201808-0920-011 · 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⚠️ Notice: This information collection may be referencing outdated material.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 57.310 57.310_HV AR-DSTR_BLANK	Form
57.310 Hemovigilance Adverse Reaction - Delayed Serologic Trans 57.310_HV AR-DSTR_BLANK.DOCX	Form

IC Title:

57.310_HV AR-DSTR_BLANK

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	57.310	Hemovigilance Adverse Reaction - Delayed Serologic Transfusion Reaction	57.310_HV AR-DSTR_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	Previously Approved
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	333	333
Annual IC Cost Burden (Dollars)	11,663	11,663

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.