Free 3611 - Federal

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

FOOD AND DRUG ADMINISTRATION

AUDIT REPORT
STATE AGENCY PROGRAM* NUMBER OF AUDITS/JOINT INSPECTIONS (Report Separtely) ** ACCEPTABLE NEEDS IMPROVEMENT

FORM FDA 3611 (9/03)

PSC Media Arts (301) 443-1090

EF

Submit quarterly report to:

Division of Federal-State Relations, HFC-150 5600 Fishers Lane, Room 12-07 Rockville, Maryland 20857 Telephone No. (301) 827-6906 FAX No. (301) 443-2143

NOTE: * Food, Feed Establishments, Medical Devices, etc. ** Report Separately, e.g. Audits (A) = #, Joint Inspections (JI) = #

Quarterly Audit Reports are to be submitted ten business days after the end of quarter (3/31, 6/30, 9/30 and 12/31). If no audits/joint inspections were performed during the quarter, a negative report is required.
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