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Form 3500 Consumer Reporting Form
MedWatch: The FDA Medical Products Reporting Program
OMB: 0910-0291
IC ID: 5858
OMB.report
HHS/FDA
OMB 0910-0291
ICR 201112-0910-001
IC 5858
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0291 can be found here:
2023-06-21 - No material or nonsubstantive change to a currently approved collection
2022-05-23 - Revision of a currently approved collection
Documents and Forms
Document Name
Document Type
Form FDA 3500
Form 3500 Consumer Reporting Form
Form and Instruction
FDA 3500 FDA Medwatch Consumer Reporting Form
MedWatch Form 3500 Reporting Form 090911.pdf
Form and Instruction
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Form 3500 Consumer Reporting Form
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 and Instruction
FDA 3500
FDA Medwatch Consumer Reporting Form
MedWatch Form 3500 Reporting Form 090911.pdf
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
Line of Business:
Health
Subfunction:
Public Health Monitoring
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
34,296
Number of Respondents for Small Entity:
0
Affected Public:
Private Sector
Private Sector:
Businesses or other for-profits
Percentage of Respondents Reporting Electronically:
20 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
34,296
0
-601,820
0
0
636,116
Annual IC Time Burden (Hours)
20,577
0
-661,906
0
0
682,483
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
No associated records found
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.