Adverse Event Pilot Program for Medical Devices

Forms and Documents

Document Name	Status
Form FDA Form 3669 Adverse Event Pilot Program for Medical Devices Form and Instruction	Modified
SS 0910 - 0471 Part B.DOC Supporting Statement B	2007-09-07
SS 0910 - 0471 Part A.DOC Supporting Statement A	2007-09-11

IC Document Collections

IC ID	Document Title	Status
37668	Adverse Event Pilot Program for Medical Devices Form and Instruction	Modified

ICR Details

OMB Control No: 0910-0471	ICR Reference No: 200709-0910-004
Status: Historical Active	Previous ICR Reference No: 200512-0910-008
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 without change	Conclusion Date: 12/03/2007
	Date Received in OIRA: 09/25/2007
Terms of Clearance: This information collection request is approved as submitted, per discussion with FDA staff explaining that after evaluating how it was working, this pilot is now considered to be an ongoing program. FDA will modify the supporting statement accordingly when resubmitting for approval.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2010	36 Months From Approved	11/30/2007
Responses	7,000	0	2,800
Time Burden (Hours)	5,001	0	2,772
Cost Burden (Dollars)	0	0	0

---

Abstract: This is an electronic reporting system for hospitals to inform FDA of problems with the use of medical devices. This system involves not only reporting but sharing of information between the participants.

---

Authorizing Statute(s): US Code: 21 USC 360 Name of Law: null
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 32670	06/13/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 51231	09/06/2007
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Adverse Event Pilot Program for Medical Devices	FDA Form 3669, FDA Form 3670	Device Safety Exchange Data Collection ,   MedSun Report Form

---

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	7,000	2,800	0	0	4,200	0
Annual Time Burden (Hours)	5,001	2,772	0	0	2,229	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $4,900,000

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

---

Common Form ICR:  No

---

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: 09/25/2007

---