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Please submit the completed MedWatch 3500A form along with information to support the report, such as scans of labels and images of the serious adverse event, to FDA via: Email (preferred method for faster processing and reviewing): CosmeticAERS@fda.hhs.gov.
The purpose of form FTB 3500 is to apply for tax-exempt status from California franchise and income tax. If the organization provides all answers and documents required, the FTB will determine if the organization qualifies for tax‑exempt status.
Form FDA 3500, a condensed version of 3500A, is used for voluntary reporting of adverse events by healthcare professionals, consumers and patients.
Purpose. Use form FTB 3500A to obtain California tax-exempt status, if the organization has a federal determination letter granting exemption under IRC Sections 501(c)(3), 501(c)(4), 501(c)(5), 501(c)(6), 501(c)(7), or 501(c)(19).
Initial reporting: Any unanticipated adverse event suspected to be caused/associated with a device must be reported to the FDA and the reviewing IRB within 10 working days of the event.
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Form 3500 should be used by health care professionals, and Form 3500B should be used by patients and consumers. Reporting by health care professionals, patients, and consumers is voluntary. Form 3500A is designed for industry, which has mandatory adverse event reporting requirements.
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.

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