Form 57.301 57.301_HV Monthly Reporting Plan_BLANK

Form Approved
OMB No. 0920-0666
Exp. Date: 11/30/2021
www.cdc.gov/nhsn

Hemovigilance Module
Monthly Reporting Plan
*Required for saving

*Facility ID#: _____________________
All reporting is facility-wide.

*Month: ______________

*Year: ____________

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)).
Public reporting burden of this collection of information is estimated to average 1 minute 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 D-74, Atlanta, GA 30333 ATTN: PRA (0920-0666).

CDC 57.301 Rev. 3, v8.8
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