Hemovigilance Module Monthly Incident Summary

[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⚠️ Notice: This information collection may be referencing outdated material.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 57.302 Hemovigilance Module Monthly Incident Summary Form and Instruction
Form CDC 57.302 Hemovigilance Module Monthly Incident Summary Form and Instruction
CDC 57.302 Hemovigilance Module Monthly Incident Summary 57.302_hv-monthly-incident-summary_NB-Clean Version.docx Form and Instruction
CDC 57.302 Hemovigilance Module Monthly Incident Summary 57.302_hv-monthly-incident-summary_NB-Clean Version.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Hemovigilance Module Monthly Incident Summary	Agency IC Tracking Number:	0920-0666

Is this a Common Form? No		IC Status: New

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 and Instruction	CDC 57.302	Hemovigilance Module Monthly Incident Summary	57.302_hv-monthly-incident-summary_NB-Clean Version.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 9	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	108	108
Annual IC Time Burden (Hours)	54	54
Annual IC Cost Burden (Dollars)	0	0

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.