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									Federal, State and Local Officials Home Patients: Ask FDA
                    
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                                    Print**This form is for:**PatientsCaregiversAdvocatesHealth Care Professionals*This form **is not**for industry stakeholders.*
	**Please use this form to:**Ask a question to FDA orRequest a meeting with FDA**To report adverse events that you observe or suspect for humanmedical products please use theMedWatch reporting form.*
	**This form is for requests about:**Diseases or Health ConditionsDrugsDevicesVaccines/Blood/Biologics*For other requests pleasevisit the FDA contacts page.*

Please tell us who you are (required):           
	
				Individual Patient, Caregiver or Advocate
				
	
				Patient Group
				
	
				Health Professional
				
	
				Other      
			
				
			
			Name of Group (if applicable):
			
			
			
			Other:		
			
			
			
		
			
			Question or Meeting Request (required):
						Question
						Meeting Request
											
						What is your request about? (required):
							a drug  
								
								
								a medical device
								  
								a vaccine, blood or biologic 
								
								disease or health condition
								multiple or unknown
						Is your request about a specific FDA program? (required):
					    Yes
													
						No, or I do not know
		
						
						FDA Patient Engagement Programs: 
							 
							Cancer/OncologyPatient Engagement Collaborative (PEC)Patient Representative Program SM (PRP)
								Patient Listening Sessions
								Expanded AccessNone/Unknown						
							
							
							
							Please note, Patient Listening Sessions: are a chance for FDA review staff to listen to patients, caregivers, and/or advocatesmay happen over the phone or face-to-face and are typically 1.5 hour meetingsare not binding agreementsmay not be used to discuss medical products under FDA review or clinical trials that patients are inWhat is the name of the disease or condition (if applicable):
									What would you like to share during your listening session? Please provide a proposed draft agenda. (required): For more information, please see the How do I request a Patient Listening Session? Webpage.
									What do you hope to happen after your listening session with FDA? (required):
								
							
							To learn more about how you can engage with FDA, [Visit our website]. 
												

			   
			
			
			Name of Disease or Condition (if applicable):
				Question (required):
			

			
			Please note: Meetings may happen face-to-face or over the phoneFDA staff may be unable to answer questionsMeetings and responses are not binding agreementsWhat is the name of the disease or condition (if applicable):
				What would you like to share during your meeting? (required):
				What do you hope to happen after your meeting with FDA? (required):
			
						
			
			Please note, Patient Listening Sessions: are a chance for FDA review staff to listen to patients, caregivers, and/or advocatesmay happen over the phone or face-to-faceare not binding agreementsmay not be used to discuss medical products under FDA review or clinical trials that patients are inWhat is the name of the disease or condition (if applicable):
				What would you like to share during your listening session? (required):
				What do you hope to happen after your listening session with FDA? (required):
			
									
			



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For problems with the form please email the Patient Affairs Staff at Webform@fda.gov
	***Note**: Meetings and responses are not intended to establish binding agreements pertaining to medical product development programs or to discuss proprietary information pertaining to specific development programs under FDA review.*
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