Form 57.301 Hemovigilance Module Monthly Reporting Plan

F orm Approved

OMB No. 0920-0666

Exp. Date: 12/31/2026

www.cdc.gov/nhsn

Hemovigilance Module

Monthly Reporting Plan

*Required for saving

*Facility ID#: _____________________	*Month: ______________	*Year: ____________
All reporting is facility-wide.
Participating in Hemovigilance Module surveillance this month
Participation requires complete reporting of all CDC-defined adverse reactions, reaction-associated incidents, and denominators for the entire month as specified in the surveillance protocol.
Adverse reactions associated with transfusions
Incidents (i.e., errors or accidents) associated with adverse reactions
Denominators (i.e., transfused components and patient samples collected)
Not participating in Hemovigilance Module surveillance this month

Assurance of Confidentiality: The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). CDC 57.301 Rev. 4, v9.2

Public reporting burden of this collection of information is estimated to average 1 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering, and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS H21-8, Atlanta, GA 30333, ATTN: PRA (0920-0666).

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