57.305 Hemovigilance Incident

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⚠️ Notice: This information collection may be referencing outdated material.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 57.305 57.305 Hemovigilance Incident Form
CDC 57.305 Hemovigilance Module Incident 57.305_HV Incident_BLANK.docx Form
CDC 57.305 Hemovigilance Module Incident 57.305_HV Incident_BLANK.docx Form
Att G3_Biovigilance Component.pdf Att G3_Bioviligance Component IC Document
Att G3_Biovigilance Component.pdf Att G3_Bioviligance Component IC Document

Information Collection (IC) Details

IC Title:	57.305 Hemovigilance Incident	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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 57.305	Hemovigilance Module Incident	57.305_HV Incident_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	Previously Approved
Annual Number of Responses for this IC	5,000	5,000
Annual IC Time Burden (Hours)	833	833
Annual IC Cost Burden (Dollars)	29,155	29,155

Documents for IC

Title	Document	Date Uploaded
Att G3_Bioviligance 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.