57.319 Hemovigilance Adverse Reaction - Unknown 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⚠️ Notice: This information collection may be referencing outdated material.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 57.319 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction Form
Form CDC 57.319 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction Form
CDC 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Rea 57.319_HV AR-UNK_BLANK.docx Form
CDC 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Rea 57.319_HV AR-UNK_BLANK.docx Form
CDC 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Rea 57.319_HV-AR-UNK_OMB.docx Form
CDC 57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Rea 57.319_HV-AR-UNK_OMB.docx Form
57.319_HV-AR-UNK_OMB.docx Hemovigilance Adverse Reaction - Unknown Transfusion Reaction (with modified GISAB questions in tracked changes) IC Document
57.319_HV-AR-UNK_OMB.docx Hemovigilance Adverse Reaction - Unknown Transfusion Reaction (with modified GISAB questions in tracked changes) IC Document

Information Collection (IC) Details

IC Title:	57.319 Hemovigilance Adverse Reaction - Unknown Transfusion Reaction	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	CDC 57.319	Hemovigilance Adverse Reaction - Unknown Transfusion Reaction	57.319_HV AR-UNK_BLANK.docx		Yes	Yes	Fillable Printable
Form	CDC 57.319	Hemovigilance Adverse Reaction - Unknown Transfusion Reaction (with modified GISAB questions)	57.319_HV-AR-UNK_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	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	175	175
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Hemovigilance Adverse Reaction - Unknown Transfusion Reaction (with modified GISAB questions in tracked changes)	57.319_HV-AR-UNK_OMB.docx	04/25/2023

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