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S NAME AND ADDRESS If you do NOT want your identity disclosed to the manufacturer, place an "X" in this box. 2. OWNER S NAME OR CASE ID (In Confidence) 3. NADA NUMBER (For FDA Use) TELEPHONE (Include Area Code) 4. SUSPECTED DRUG AND DOSAGE FORM 5. MANUFACTURER S NAME 6. DIAGNOSIS AND / OR REASON FOR USE OF DRUG 7. ADMINISTERED BY VETERINARIAN OWNER 8. DOSAGE ADMINISTERED AND ROUTE (Ex. 250 mg. q 12h, 5 days, orally) 10. SPECIES 11. BREED 9. DATE(S) OF ADMINISTRATION 12. AGE 1.

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Form FDA 3500 may be used by health professionals or consumers for VOLUNTARY reporting of adverse events, product use/medication errors, product quality problems, and therapeutic failures for: Prescription and over-the-counter medicines including those administered in a hospital or outpatient infusion centers.

The MedWatch form, also known as Form FDA 3500A, is used for mandatory reporting of medical device adverse events by manufacturers, user facilities and importers. Form FDA 3500, a condensed version of 3500A, is used for voluntary reporting of adverse events by healthcare professionals, consumers and patients.

List and provide product names and therapy dates for any other medical products (drugs, biologics, including human cells, tissues, and cellular and tissue-based products (HCT/Ps), or medical devices, etc.) that the patient was using at the time of the event.

Form FDA 3500A is used for mandatory reporting (i.e., required by law or regulation), primarily by regulated industry reporters but also for certain User Facility reporters for reports related to deaths associated with medical devices.

Animal foods and FDA-approved products, such as animal medications and devices –report the adverse event to the FDA online or by calling 1-888-FDA-VETS (1-888-332-8387).

Reporting can be done through our online reporting portal or by downloading, completing and then submitting FDA Form 3500 (health professional) or 3500B (consumer/patient) to MedWatch: The FDA Safety Information and Adverse Event Reporting Program.

Manufacturers must submit a five-day report on form FDA 3500A within five days under the following two conditions: They become aware that an MDR reportable event, from any source, requires remedial action to prevent an unreasonable risk of substantial harm to the public health.

Animal Vaccines - contact the USDA APHIS Center for Veterinary Biologics at (800) 752-6255.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232