57.300 Hemovigilance Module Annual Survey -- 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⚠️ Notice: This information collection may be referencing outdated material.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 CDC 57.300 57.300 Hemovigilance Module Annual Survey -- Acute Care Facility Form
CDC 57.300 Hemovigilance Module - Annual Survey 57.300_HV Annual Facility Survey - Non-Acute_BLANK.docx Form
CDC 57.300 Hemovigilance Module - Annual Survey 57.300_HV Annual Facility Survey - Non-Acute_BLANK.docx Form
57.300 Hemovigilance Module Annual Survey (with revised GISAB q 57.300_hv-annual-facility-survey_OMB.docx Form
57.300 Hemovigilance Module Annual Survey (with revised GISAB q 57.300_hv-annual-facility-survey_OMB.docx Form
3. Biovigilance Component.pdf Att G3_Biovigilance Component IC Document
3. Biovigilance Component.pdf Att G3_Biovigilance Component IC Document
57.300_hv-annual-facility-survey_OMB.docx Hemovigilance Module Annual Survey (with revised GISAB questions in tracked changes) IC Document
57.300_hv-annual-facility-survey_OMB.docx Hemovigilance Module Annual Survey (with revised GISAB questions in tracked changes) IC Document

Information Collection (IC) Details

IC Title:	57.300 Hemovigilance Module Annual Survey -- Acute Care Facility	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 57.300	Hemovigilance Module - Annual Survey	57.300_HV Annual Facility Survey - Non-Acute_BLANK.docx		Yes	Yes	Fillable Fileable
Form	57.300	Hemovigilance Module Annual Survey (with revised GISAB questions)	57.300_hv-annual-facility-survey_OMB.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

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, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	500	500
Annual IC Time Burden (Hours)	717	717
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Att G3_Biovigilance Component	3. Biovigilance Component.pdf	09/26/2018
Hemovigilance Module Annual Survey (with revised GISAB questions in tracked changes)	57.300_hv-annual-facility-survey_OMB.docx	04/25/2023

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