21 CFR § 803.33 - If I am a user facility, what must I include when I submit an annual report?
(a) You must submit to us an annual report on Form FDA 3419. You must submit an annual report by January 1, of each year. You may obtain this form on the internet at: https://www.fda.gov/media/72292/download.
(b) You must clearly identify your annual report as such. You must submit your annual report to FDA, CDRH, Medical Device Reporting, P.O. Box 3002, Rockville, MD 20847-3002. Your annual report must include:
(1) Your CMS provider number used for medical device reports, or the number assigned by us for reporting purposes in accordance with § 803.3;
(2) Reporting year;
(3) Your name and complete address;
(4) Total number of reports attached or summarized;
(5) Date of the annual report and report numbers identifying the range of medical device reports that you submitted during the report period (e.g., 1234567890-2011-0001 through 1000);
(6) Name, position title, and complete address of the individual designated as your contact person responsible for reporting to us and whether that person is a new contact for you; and
(7) Information for each reportable event that occurred during the annual reporting period including:
(i) Report number;
(ii) Name and address of the device manufacturer;
(iii) Device brand name and common name;
(iv) Product model, catalog, serial, and lot number and unique device identifier (UDI) that appears on the device label or on the device package;
(v) A brief description of the event reported to the manufacturer and/or us; and
(c) In lieu of submitting the information in paragraph (b)(7) of this section, you may submit a copy of each medical device report that you submitted to the manufacturers and/or to us during the reporting period.
(d) If you did not submit any medical device reports to manufacturers or us during the time period, you do not need to submit an annual report.