57.305 Hemovigilance Incident

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⚠️ Notice: This information collection may be referencing outdated material.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 57.305 57.305 Hemovigilance Incident Form
CDC 57.305 Hemovigilance Module Monthly Reporting Denominators 57.305_HV Incident_BLANK.doc Form
Att G.2_ Biovigilance Component.pdf Att G.2_NHSN Biovigilance Component: Hemovigilance Module Surveillance Protocol IC Document

Information Collection (IC) Details

IC Title:	57.305 Hemovigilance Incident	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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 57.305	Hemovigilance Module Monthly Reporting Denominators	57.305_HV Incident_BLANK.doc		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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	5,000	-1,000	6,000
Annual IC Time Burden (Hours)	833	-167	1,000
Annual IC Cost Burden (Dollars)	27,617	-5,523	33,140

Documents for IC

Title	Document	Date Uploaded
Att G.2_NHSN Biovigilance Component: Hemovigilance Module Surveillance Protocol	Att G.2_ Biovigilance Component.pdf	08/28/2014

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