57.307 Hemovigilance Adverse Reaction - Acute 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⚠️ Notice: This information collection may be referencing outdated material.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 57.307 57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction Form
57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfu 57.307_HV AR-AHTR_BLANK.docx Form
57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfu 57.307_HV AR-AHTR_BLANK.docx Form
CDC 57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfu 57.307_HV-AR-AHTR_OMB.docx Form
CDC 57.307 Hemovigilance Adverse Reaction - Acute Hemolytic Transfu 57.307_HV-AR-AHTR_OMB.docx Form
57.307_HV-AR-AHTR_OMB.docx Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction (with revised GISAB questions in tracked changes) IC Document
57.307_HV-AR-AHTR_OMB.docx Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction (with revised GISAB questions in tracked changes) IC Document

Information Collection (IC) Details

IC Title:	57.307 Hemovigilance Adverse Reaction - Acute Hemolytic 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	57.307	Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction	57.307_HV AR-AHTR_BLANK.docx		Yes	Yes	Fillable Printable
Form	CDC 57.307	Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction (with revised GISAB questions)	57.307_HV-AR-AHTR_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 %

	Requested	Previously Approved
Annual Number of Responses for this IC	2,000	2,000
Annual IC Time Burden (Hours)	700	700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Hemovigilance Adverse Reaction - Acute Hemolytic Transfusion Reaction (with revised GISAB questions in tracked changes)	57.307_HV-AR-AHTR_OMB.docx	04/25/2023

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