Form FDA Form 3669 FDA Form 3669 Device Safety Exchange Data Collection

OMB 0910-0471

EXP. Date 09/ 30/ 2007

FDA Form: 3669

Public reporting burden for this collection of information is estimated to average 30 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. 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, t

Device Safety Exchange Data Collection

The Device Safety Exchange ( DS – X), provides you with the ability to ask questions of and dialogue with your MedSun peers about device safety concerns. Please provide as much information as you feel is necessary. Items with an asterisk (*) are required.

1 A. Ask your question:(*)

B. Provide any additional information about your question:

2. If you want to tell a safety story about a device', please type the story on a different

web page.