Attachment_2C_MQSA_COURSE_III_MENTORSHIP_REQUIREMENT_5_1_14.doc

Attachment 2C

MQSA COURSE III

MENTORSHIP REQUIREMENT

MQSA Inspector Name: ______________________________MQSA Inspector I.D. #: _______

COMMENTS:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ I, ____________________ verify that the above MQSA inspector performed these inspections Supervisor Name/Title satisfactorily under the observation of the above MQSA Certified Inspector.

Please complete this requirement within three months of your completion of Course III Email the completed form to Michelle.garza@fda.hhs.gov or fax to (301) 847-8502 Attn: Michelle Garza. A copy of this form must also be sent to your FDA Regional Radiological Health Representative. If you have any questions, please contact me.

Michelle Garza Training Coordinator Program Management Branch Division of Mammography Quality Standards

FDA/CDRH/OIR

E-Mail: michelle.garza@fda.hhs.gov

Phone: 301-796-6684 Fax: 301-847-8502