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Form Approved: OMB No. 0910-0120; Expiration Date: 8/31/10

Department of Health and Human Services Food and Drug Administration Center for Devices and Radiological Health

PREMARKET NOTIFICATION [510(K)] STATUS REQUEST AND RESPONSE

Single Form ­ To be used for both your request and FDA's response. Requesters should fill in the information on the top half of this form (Request Section) and fax (or mail) this form to the FDA at the fax # or address listed below. The FDA will complete the information on the bottom half (Response Section) and return by fax (or mail). REQUEST SECTION (To be completed by requester)
To (From) From (To) REQUESTER NAME MAILING ADDRESS

FDA, Center for Devices & Radiological Health Division of Small Manufacturers, International and Consumer Assistance (DSMICA) Attn: 510(k) Status Coordinator 1350 Piccard Drive (HFZ-220) Rockville, MD 20850 USA Fax Number: (240) 276-3151 Phone: (240) 276-3150 or (800) 638-2041

FAX NUMBER

TELEPHONE NUMBER REQUESTER'S AFFILIATION WITH THE SUBMITTER OF THE 510(K)

Requester Certification: I certify that I am an authorized representative of the submitter of the following 510(k) and that all information provided herein is truthful to the best of my knowledge. Please provide me with information related to the status of the following 510(k) submission via (mark one): FAX or MAIL
510(K) NUMBER REQUESTER SIGNATURE

SPONSOR'S NAME AND ADDRESS

PRODUCT NAME

DATE LOGGED IN BY FDA (ODE) ­ as identified in acknowledgement letter

RESPONSE SECTION (To be completed by FDA) NOTE: THIS DOCUMENT IS INTENDED ONLY FOR THE USE OF THE PARTY TO WHOM IT IS ADDRESSED AND CONTAINS INFORMATION THAT IS PRIVILEGED, CONFIDENTIAL, AND PROTECTED FROM DISCLOSURE UNDER APPLICABLE LAW. If you are not the addressee, or authorized to deliver this document to the addressee, you are hereby notified that review, disclosure, dissemination, copying, or other action based on the content of this communication is not authorized. If document has been received in error, please notify FDA by phone and return via mail. Reviewing Branch: Please be advised that the average total time (time for FDA review plus time spent awaiting any additional data) for review of a device assigned to days over the last 6 months. this branch has been Place in Queue: Your 510(k) has been assigned to a reviewer and is # in line for that reviewer to work on. The length of time that it will take for the reviewer to get to your 510(k) and to review it will depend on many factors, such as the complexity of the 510(k)'s that are in line ahead of you, and other work assigned to the reviewer, for example the review of investigational device FDA RESPONSE DATE (Please do not request another exemption submissions. Due to these variables, we cannot status report prior to 30 days from the FDA response date.) estimate a completion date for review of your 510(k). However, future inquiries can give you an idea of how your Please do not request another status report prior to 30 510(k) is progressing. days from the FDA response date.
FORM FDA 3541 (9/07) Page 1
PSC Graphics: (301) 443-1090

LAST ACTION AND DATE

EF

Public Reporting burden for this collection of information is estimated to average 0.2 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Food and Drug Administration Center for Devices & Radiological Health Division of Small Manufacturers, International and Consumer Assistance (DSMICA) 1350 Piccard Drive (HFZ-220) Rockville, MD 20850

FORM FDA 3541 (9/07)

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