Adverse Event Pilot Program for Medical Devices

Forms and Documents

Document Name	Status

No forms / supporting documents in this ICR. Check IC Document Collections.

IC Document Collections

IC ID	Document Title	Status
6169	Adverse Event Pilot Program for Medical Devices	Migrated

ICR Details

OMB Control No: 0910-0471	ICR Reference No: 200406-0910-004
Status: Historical Active	Previous ICR Reference No: 200403-0910-005
Agency/Subagency: HHS/FDA	Agency Tracking No:
Title: Adverse Event Pilot Program for Medical Devices
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 09/03/2004
	Date Received in OIRA: 06/24/2004
Terms of Clearance: This collection is approved as amended by FDA's revisions of 9/2/04 on the following conditions: If FDA determines that modifications to the collection are necessary during the course of the pilot (e.g., expansion of the number of respondents, questions asked), FDA shall request OMB approval of the changes through a memorandum explaining the need for such changes prior to initiating a revised collection. Once approved, OMB will amend the file accordingly. FDA should also send OMB an update on the progress of the pilot prior to the development of the regulation.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2007	09/30/2007	09/30/2004
Responses	3,960	0	2,045
Time Burden (Hours)	2,680	0	1,334
Cost Burden (Dollars)	0	0	0

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Abstract: This pilot includes: continuing to implement an electronic version of the portions of the 3500A form used by user facilities to report adverse events occurring with medical devices (which includes past approved additional voluntary questions); and continuing to implement a sharing of device problems between the reporting sites with the opportunity to provide solutions. Participation in this pilot is voluntary. During the first three years of the program 180 facilities were enrolled. It is anticipated that the number of voluntary participants will increase to approximately..

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Adverse Event Pilot Program for Medical Devices

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,960	2,045	0	1,915	0	0
Annual Time Burden (Hours)	2,680	1,334	0	1,346	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 06/24/2004

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