Experiential
Learning Program
(ELP) – Sample Site
Visit Request
Area of interest addressed:
Total product life cycle of [insert medical
device specialty]
Area of Interest Identifier Code:
Q1 A1
Contact person:
Wendy Schumer
Senior Vice President, Regulatory Affairs
Medical Devices, Inc.
123 Technology Way
Generic City, TX 55555
Phone: 555-123-4567
Email: [email protected]
Site visit location:
Medical Devices, Inc.
123 Technology Way
Generic City, TX 55555
FDA Establishment Identifier
(FEI #) if applicable
123456789
Length of site visit:
2 Days
Proposed dates:
June 3 - 4, 2014
Week of June 9, 2014
July 16 - 17, 2014
Week of August 4, 2014
Does your proposal also align with the Patient
Engagement Initiative?
Please check: Yes or No
Yes
No
Is the content in your proposal able to be
Yes
No
accommodated virtually
Maximum number of CDRH
participants that can be accommodated:
10
Experiential
Learning Program
(ELP) – Sample Site
Visit Request
