FDA 3756 - Proof Form

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration

Form Approved: OMB No. xxxx-xxxx
Expiration Date: xx/xx/xxxx
(See Burden Statement on last form page)

Pet Event Tracking Network (PETNet) Electronic Report

Note: Items with an asterisk (*) require a response.

Case Number
1.) Pet Food
Product
Details

Name of Pet Food*
(Please provide accurate name, check
spelling)

Add Row
Delete Row

Product Form
(Select one)

Manufacturer

Dry kibble

Pellets

Semi-moist

Liquid

Can

Treat

Designer note: The word “Form” should be avoided in a form’s title. Other options:
Pet Event Tracking Network (PETNet) Electronic Reporting Record
Pet Event Tracking Network (PETNet) Electronic Reporting Report (may be
accurate, but seems redundant),
or maybe simply Pet Event Tracking Network (PETNet) Electronic Reporting

Pouch

ns
(Dummy butto
form)
on this proof

Distributor/Packer

Other (Specify below)

The alternate form version using continuation
pages would be used instead if the Add/Delete
row function causes acute problems with “508
compliance” aspects of the form.

Populate the table for one (1) or more products; use the Add and Delete buttons accordingly.
Use one (1) row for per each product.

F
O
O

2.) Species* (Select one)
Dog

Rabbit

Cat

Small Mammal

Caged Bird

Aquarium/Ornamental Fish

Reptile

Other (Specify):

PR

3.) Number of Animals Exposed* (Enter exact number, an
estimate, or select unknown)
Unknown
4.) Number of Animals Affected (Enter exact number or an
estimate)

5.) Animal Life Stage* (Select all that apply)
Fetal

Neonate

Juvenile

Adult

Geriatric

All ages

Unknown

6.) Clinical Signs* (Select all that apply)
Gastrointestinal

Neurologic/Sensory

Musculoskeletal

Dermatologic

Pulmonary

Endocrine

Cardiovascular

Immunologic

Reproductive

Metabolic

Renal

Hepatic

Death

Other Clinical SIgn

None
FORM FDA 3756 (7/10)

PSC Graphics (301) 443-1090

EF

Page 1 of

7.) Product Problem/Defect* (Select all that apply)

8.) Date of onset (mm/dd/yyyy)

Foreign object in package/container

Nutrient excess

Package damaged

Error in formulation

Swollen package

Other contamination including
chemical/toxic

Mold contamination
Bacterial contamination

Unknown

Nutrient deficient
10.) Data Origin (Select one)

9.) State* (May choose “Multiple States”
or “Outside U.S.” options)
We probably could duplicate the State
listing, but we might also need to make
a manual fill-in option for the visually
impaired. Also, we’re assuming that your
information requirements, and not distrust
of user ability, are what prevent you from
asking user to simply type actual multiple
States or actual non-U.S. countries.
Food testing laboratory

Diagnostic lab

Reportable food registry

Private practitioner

Consumer complaint/report

Veterinary diagnostic laboratory

Referral practice

State inspection

Other (Specify below)

Veterinary college

FDA inspection

Manufacturer/Packer/Distributor/
Retailer

Surveillance sampling

11.) Are there any laboratory test results available to share?
Yes

No

12.) PETNet Member Contact Information

F
O
O

Will remove above “(Specify below)” and
entry space if not needed.

PR

a. First name

b. Last name

c. Telephone number

d. Email address

Submit by Email

Print Form

Public reporting burden for this collection of information is estimated to average 36 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. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to the address to:
Department of Health and Human Services
Food and Drug Administration
Office of the Chief Information Officer
1350 Piccard Drive, Room 400
Rockville, MD 20850

Please do NOT return this
form to this address.

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.
FORM FDA 3756 (7/10)

Page numbers will be automatic, so this page number could increase.

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INSTRUCTIONS for
Pet Event Tracking Network (PETNet) Electronic Report – FORM FDA 3756
General Instructions: This form is to be used by Food and Drug Administration (FDA) employees and
State government employees who are PETNet members to report suspected pet food-related illnesses in
animals, as well as pet food product problems or defects.
This reporting system applies to pet food products. For the purposes of this form, pet food products
include pet foods, pet treats, bones, chews, nutritional supplements, and liquid products intended for pet
consumption. This reporting system does not include animal drugs.
Case Number – (automated process/no action necessary)
1. Pet Food Product Details – Provide as much information as possible about the product(s) in this
report. Enter the name of the pet food, select product form, enter the pet food manufacturer, and the
distributor/packer of the pet food. If unknown leave blank. Click the “add row” button on the left side of
the screen to enter information for additional product(s). Repeat this process for each product.
2. Species – Select one (1) entry from among those listed. If you select Other, specify in the space
provided. Use one form per animal species.
3. Number Of Animals Exposed – Enter the number or estimated number of animals exposed to
product(s) listed in section 1. If no animal were exposed enter 0. If the number of animals is not known
select Unknown.
4. Number Of Animals Affected – Enter the number or estimated number of animals affected.

F
O
O

5. Animal Life Stage – Select all that apply. If unknown, select Unknown.

PR

6. Clinical Signs – Select all that apply. If no illness occurred select None.
7. Product Problem/Defect – Select all that apply. If unknown, select Unknown.
8. Date Of Onset – Use the drop down calendar or otherwise enter the date (in mm/dd/yyyy format) of
onset of illness or the date the product problem/defect was first identified.
9. State – Select from the drop down menu the State where the incident was reported. Select the option
of “Multiple States” if the incident covered more than one State or “Outside U.S.” if occurrence was
outside U.S. borders.
10. Data Origin – Select one (1) entry from among those listed.
11. Laboratory Test Results – Indicate whether there are laboratory test results available to share.
12. PETNet Member Contact Information
a. & b. First & Last Name – Self-explanatory
c. Phone Number – Enter contact phone number for the PETNet member.
d. Email Address – Enter email address for the PETNet member.
Submit by Email – Click the Submit by Email button to send the completed form by email to PETNet on
the FoodSHIELD web server.
Print Form – PETNet FORM FDA 3756 may be printed if desired.

FORM FDA 3756 (7/10)

of this text to
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in the form
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agree with the change
sic info is the
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format. Otherwise the
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same as in the origin
Instructions Page

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration

Form Approved: OMB No. xxxx-xxxx
Expiration Date: xx/xx/xxxx
(See Burden Statement on last form page)

Pet Event Tracking Network (PETNet) Electronic Report

Note: Items with an asterisk (*) require a response.

Case Number
1.) Pet Food
Product
Details

Name of Pet Food*
(Please provide accurate name, check
spelling)

Product Form
(Select one)

Manufacturer

Dry kibble

Pellets

Semi-moist

Liquid

Can

Treat

Pouch

Distributor/Packer

E
WITH CONTINUATION P
PAGE BUTTON AND
SAMPLE CONTINUATION
U
PAGE

Other (Specify below)

Populate the table for one (1) or more products; use the Add Continuation Page button for additional rows.
Use one (1) row for per each product.

F
O
O

2.) Species* (Select one)
Dog

Rabbit

Cat

Small Mammal

Caged Bird

Aquarium/Ornamental Fish

Reptile

Other (Specify):

PR

(Dummy buttons
on this proof form)

Add Continuation Page

3.) Number of Animals Exposed* (Enter exact number, an
estimate, or select unknown)
Unknown
4.) Number of Animals Affected (Enter exact number or an
estimate)

5.) Animal Life Stage* (Select all that apply)
Fetal

Neonate

Juvenile

Adult

Geriatric

All ages

Unknown

6.) Clinical Signs* (Select all that apply)
Gastrointestinal

Neurologic/Sensory

Musculoskeletal

Dermatologic

Pulmonary

Endocrine

Cardiovascular

Immunologic

Reproductive

Metabolic

Renal

Hepatic

Death

Other Clinical SIgn

None
FORM FDA 3756 (7/10)

PSC Graphics (301) 443-1090

EF

Page 1 of

1.) Pet Food
Product
Details

Name of Pet Food*
(Please provide accurate name, check
spelling)

Product Form
(Select one)

Manufacturer

Dry kibble

Pellets

Semi-moist

Liquid

Can

Treat

Distributor/Packer

Pouch
Other (Specify below)

Dry kibble

Pellets

Semi-moist

Liquid

Can

Treat

Pouch
Other (Specify below)

Dry kibble

Pellets

Semi-moist

Liquid

Can
Pouch

F
O
O

PR

Treat

Other (Specify below)

Dry kibble

Pellets

Semi-moist

Liquid

Can

Treat

Pouch
Other (Specify below)

Use the Add Continuation Page button for additional rows, or use the Return to Main Form button.
FORM FDA 3756 (7/10)

Continuation Page

Add Continuation Page

Return to Main Form
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