Information Collection

Adverse Event Reporting Follow-up Survey

IC 7729 under ICR 200810-0935-002 · OMB 0935-0125.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form Form #1 Questionnaire -- Mailed Version Adverse Event Reporting Follow-up Survey	Form and Instruction
Form Form #2 Questionnaire -- Telephone Version Adverse Event Reporting Follow-up Survey	Form and Instruction
Form #1 Questionnaire -- Mailed Version Attachment A -- Risk Manager Questionnaire -- Mail Version.doc	Form and Instruction
Form #2 Questionnaire -- Telephone Version Attachment B -- Risk Manager Questionnaire -- Phone Version.doc	Form and Instruction
Attachment C -- Questionnaire Cover Letter.doc Attachment C -- Questionnaire Cover Letter	IC Document
Attachment D -- Reminder Post Card.doc Attachment D -- Reminder Post Card	IC Document
Attachment E -- Remail Cover Letter.doc Attachment E -- Remail Cover Letter	IC Document
Attachment F -- Phone Survey Intro Script.doc Attachment F -- Phone Survey Intro Script	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form #1				No	No	Paper Only
Form and Instruction	Form #2				No	No	Paper Only

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,020

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: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,020	1,020
Annual IC Time Burden (Hours)	425	425
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment C -- Questionnaire Cover Letter		10/06/2008
Attachment D -- Reminder Post Card		10/06/2008
Attachment E -- Remail Cover Letter		10/06/2008
Attachment F -- Phone Survey Intro Script		10/06/2008

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

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