57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction

[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⚠️ Notice: This information collection may be referencing outdated material.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 CDC 57.309 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction Form
CDC 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Trans 57.309_HV AR-DHTR_BLANK.docx Form
CDC 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Trans 57.309_HV AR-DHTR_BLANK.docx Form
CDC 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Trans 57.309_HV-AR-DHTR_OMB.docx Form
CDC 57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Trans 57.309_HV-AR-DHTR_OMB.docx Form
57.309_HV-AR-DHTR_OMB.docx Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction (with revised GISAB questions in tracked changes) IC Document
57.309_HV-AR-DHTR_OMB.docx Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction (with revised GISAB questions in tracked changes) IC Document

Information Collection (IC) Details

IC Title:	57.309 Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction	Agency IC Tracking Number:	0920-0666

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	CDC 57.309	Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction	57.309_HV AR-DHTR_BLANK.docx		Yes	Yes	Fillable Printable
Form	CDC 57.309	Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction (with revised GISAB questions)	57.309_HV-AR-DHTR_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)	175	8	167
Annual IC Cost Burden (Dollars)	0	-5,832	5,832

Documents for IC

Title	Document	Date Uploaded
Hemovigilance Adverse Reaction - Delayed Hemolytic Transfusion Reaction (with revised GISAB questions in tracked changes)	57.309_HV-AR-DHTR_OMB.docx	04/25/2023

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