Information Collection

57.312_hv Ar-htr_blank

IC 222899 under ICR 202212-0920-013 · 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⚠️ Notice: This information collection may be referencing outdated material.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 57.312 57.312_HV AR-HTR_BLANK	Form
Form 57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion Reaction 57.312_HV AR-HTR_BLANK	Form
57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion 57.312_HV AR-HTR_BLANK.docx	Form
57.312 Hemovigilance Adverse Reaction - Hypotensive Transfusion 57.312_HV AR-HTR_BLANK.docx	Form

IC Title:

57.312_HV AR-HTR_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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	57.312				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	500	500
Annual IC Time Burden (Hours)	167	167
Annual IC Cost Burden (Dollars)	5,832	5,832

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.

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