Coordination with third-party entities related to screener response

Attachment B

Small Dispensers Assessment Under the Drug Supply Chain Security Act

Screener

OMB Control Number 0910-####

Expiration Date ##/##/####

Paperwork Reduction Act Statement: The Paperwork Reduction Act of 1995 provides that an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0910-####. The time required to complete this information collection is estimated to average 6 minutes per response. Send comments regarding this burden estimate or any other aspects of this collection of information, including suggestions for reducing burden to PRAStaff@fda.hhs.gov.

The survey we are conducting is on behalf of the U.S. Food and Drug Administration (FDA).

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INTRODUCTION/START PAGE

(Title/Header) FDA's DSCSA Small Dispensers Assessment

CONFIRMING SMALL DISPENSER:

• Confirm you are (check one):

  • A small dispenser with 25 or fewer full-time employees.

  • An entity representing a small dispenser (with 25 or fewer full-time employees) and completing this assessment on behalf of such dispenser.

Exit Option: If neither of these apply, please exit the assessment.