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DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration

Form Approved: OMB No. 0910-0396 Expiration Date: August 31, 2012

DISCLOSURE: FINANCIAL INTERESTS AND ARRANGEMENTS OF CLINICAL INVESTIGATORS
TO BE COMPLETED BY APPLICANT

The following information concerning as a clinical investigator in the submitted study
clinical study

Name of clinical investigator

, who participated
Name of

is submitted in accordance with 21 CFR part 54. The

named individual has participated in financial arrangements or holds financial interests that are required to be disclosed as follows:
Please mark the applicable check boxes.

any financial arrangement entered into between the sponsor of the covered study and the clinical investigator involved in the conduct of the covered study, whereby the value of the compensation to the clinical investigator for conducting the study could be influenced by the outcome of the study; any significant payments of other sorts made on or after February 2, 1999, from the sponsor of the covered study, such as a grant to fund ongoing research, compensation in the form of equipment, retainer for ongoing consultation, or honoraria; any proprietary interest in the product tested in the covered study held by the clinical investigator; any significant equity interest, as defined in 21 CFR 54.2(b), held by the clinical investigator in the sponsor of the covered study. Details of the individual's disclosable financial arrangements and interests are attached, along with a description of steps taken to minimize the potential bias of clinical study results by any of the disclosed arrangements or interests.
NAME TITLE

FIRM/ORGANIZATION

SIGNATURE

Date (mm/dd/yyyy)

Paperwork Reduction Act Statement
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Public reporting burden for this collection of information is estimated to average 4 hours per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the necessary data, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information to: Department of Health and Human Services Food and Drug Administration Office of Chief Information Officer 1350 Piccard Drive, 420A Rockville, MD 20850

FORM FDA 3455 (10/09)

PSC Graphics (301) 443-1090

EF