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PDF format Reporting Forms

 

* IMPORTANT * Form FDA 3500A [mandatory] presently displays an expiration date of 12/31/2011. You may continue to use them while the reporting forms are under review for renewal by the US Office of Management and Budget. Mandatory reporters, see OMB Reginfo.gov page for submission status at http://www.reginfo.gov/public/do/PRAViewICR?ref_nbr=201112-0910-001

 

These forms are fillable on your computer using the free Adobe Acrobat Reader. You can also choose to print the blank form and fill it out by hand. The Voluntary Form FDA 3500 features a postage-paid pre-addressed mailer.

• Form FDA 3500 - Voluntary Reporting

  • For use by healthcare professionals, consumers, and patients. Submit the completed form using supplied postage-paid mailer or fax to 1-800-332-0178.
    Instructions for Completing Form FDA 3500

• Form FDA 3500B - Voluntary Reporting for Consumers

  • A consumer-friendly version of the 3500 reporting form.

• Form FDA 3500A - Mandatory Reporting

  • For use by IND reporters, manufacturers, distributors, importers, user facilities personnel
    Instructions for Completing Form FDA 3500A

 

Online Reporting Form (Voluntary Reporting)

Report serious adverse events online for human medical products, including potential and actual product use errors, product quality problems, and therapeutic inequivalence/failure. The introductory page features additional information and instructions.