57.320_HV AR-Other_BLANK

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⚠️ Notice: This information collection may be referencing outdated material.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 57.320 57.320_HV AR-Other_BLANK Form
57.320 Hemovigilance Adverse Reaction - Other Transfusion React 57.320_HV AR-Other_BLANK.DOCX Form
57.320 Hemovigilance Adverse Reaction - Other Transfusion React 57.320_HV AR-Other_BLANK.DOCX Form

Information Collection (IC) Details

IC Title:	57.320_HV AR-Other_BLANK	Agency IC Tracking Number:	0920-0666

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	57.320	Hemovigilance Adverse Reaction - Other Transfusion Reaction	57.320_HV AR-Other_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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	5,832	5,832

Documents for IC

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.