57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility

[NCEZID] 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⚠️ Notice: This information collection may be referencing outdated material.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 57.306 57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility Form
57.306 Hemovigilance Module Annual Survey - Non-acute Care Faci 57.306_HV Annual Facility Survey - Non-Acute_BLANK.docx Form
57.306 Hemovigilance Module Annual Survey - Non-acute Care Faci 57.306_HV Annual Facility Survey - Non-Acute_BLANK.docx Form
CDC 57.306 Hemovigilance Module Annual Facility Survey - Non-acute 57.306_hv-annual-facility-survey-non-acute_OMB.docx Form
CDC 57.306 Hemovigilance Module Annual Facility Survey - Non-acute 57.306_hv-annual-facility-survey-non-acute_OMB.docx Form
57.306_hv-annual-facility-survey-non-acute_OMB.docx 57.306 Hemovigilance Module Annual Survey - Non-acute Care Facilities (with revised GISAB questions in tracked changes) IC Document
57.306_hv-annual-facility-survey-non-acute_OMB.docx 57.306 Hemovigilance Module Annual Survey - Non-acute Care Facilities (with revised GISAB questions in tracked changes) IC Document

Information Collection (IC) Details

IC Title:	57.306 Hemovigilance Module Annual Facility Survey - Non-acute Care Facility	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	57.306	Hemovigilance Module Annual Survey - Non-acute Care Facility	57.306_HV Annual Facility Survey - Non-Acute_BLANK.docx		Yes	Yes	Fillable Printable
Form	CDC 57.306	Hemovigilance Module Annual Facility Survey - Non-acute Care Facilities (with revised GISAB questions)	57.306_hv-annual-facility-survey-non-acute_OMB.docx		Yes	Yes	Fillable Fileable

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	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	500	0	500
Annual IC Time Burden (Hours)	300	8	292
Annual IC Cost Burden (Dollars)	0	-10,205	10,205

Documents for IC

Title	Document	Date Uploaded
57.306 Hemovigilance Module Annual Survey - Non-acute Care Facilities (with revised GISAB questions in tracked changes)	57.306_hv-annual-facility-survey-non-acute_OMB.docx	04/25/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.