LATEX EXAMINATION GLOVES, POWDER FREE, POLYMER COATED

{0}------------------------------------------------ Image /page/0/Picture/1 description: The image shows the seal of the U.S. Department of Health & Human Services. The seal is circular and contains the words "DEPARTMENT OF HEALTH & HUMAN SERVICES • USA" around the perimeter. In the center of the seal, there is a stylized image of three human profiles facing to the right, with flowing lines above them. ### Public Health Service Food and Drug Administration 9200 Corporate Boulevard Rockville MD 20850 #### JUN 7 2002 Ms. Linga Sumarta Arista Latindo Industrial, Limited Private 128 Jalan Kyai Haji Muhammad Mansyur. Jakarta Barat, INDONESIA 11210 Re: K021412 Trade/Device Name: Latex Examination Gloves, Powder Free, Polymer Coated Regulation Number: 880.6250 Regulation Name: Patient Examination Gloves Regulatory Class: I Product Code: LYY Dated: April 29, 2002 Received: May 3, 2002 Dear Ms. Sumarta: We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration. If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to such additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register. {1}------------------------------------------------ Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); good manufacturing practice requirements as set forth in the quality systems (OS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050. This letter will allow you to begin marketing your device as described in your Section 510(k) premarket notification. The FDA finding of substantial equivalence of your device to a legally marketed predicate device results in a classification for your device and thus, permits your device to proceed to the market. If you desire specific advice for your device on our labeling regulation (21 CFR Part 801 and additionally 21 CFR Part 809.10 for in vitro diagnostic devices), please contact the Office of Compliance at (301) 594-4618. Additionally, for questions on the promotion and advertising of your device, please contact the Office of Compliance at (301) 594-4639. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97). Other general information on your responsibilities under the Act may be obtained from the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number (800) 638-2041 or (301) 443-6597 or at its Internet address http://www.fda.qov/cdrh/dsma/dsmamain.html Sincerely yours, Susan Runner Timothy A. Ulatowski Director Division of Dental, Infection Control and General Hospital Devices Office of Device Evaluation Center for Devices and Radiological Health {2}------------------------------------------------ Image /page/2/Picture/1 description: The image shows a black and white symbol that appears to be a stylized design. It features a circle with a triangular shape inside, pointing upwards. The triangle is formed by three lines that converge at a point, and the circle seems to be partially obscured or intersected by the triangle's lines, creating a unique and abstract visual. ### ARISTA LATINDO INDUSTRIAL LTD. P.T SLOVE MANUFACTURER OFFICE : JL, K.H. MOH. MANSYUR 128 JAKARTA 11210 - INDONESIA MAILING ADDRESS : P.O. BOX 4129 JKT 11041 · INDONESIA TELEPHONE : (021) 639-1907 (4 LINES) FAX : (62-21) 669-0428, 874-0979 TELEX : 42004 NIKKO IA Section No. 3. # ATTACHMENT #2 # INDICATIONS FOR USE STATEMENT | Applicant: | PT. ARISTA LATINDO IND. LTD. | |---------------------------|-------------------------------------------------------| | 510(k) Number (if known): | | | Device Name: | Latex Examination Gloves, Powder Free, Polymer Coated | | Indications For Use: | | A patient examination glove is a disposable device intended for medical purpose that is worn on the examiner's hand or finger to prevent contamination between patient and examiner. IPLEASE DO NOT WRITE BELOW THIS LINE - CONTINUE ON ANOTHER PAGE IF NEEDED) Concurrence of CDRH Office of Device Evaluation (ODE) Preseription Use Per 21 CFR 801.109 ਾਕ Over-The-Counter______________________________________________________________________________________________________________________________________________________________ (Optimal Format 1-2-96) Olim S. hn (Division Sign-Off) Division of Dental, Infection Control, and General Hospital Device 510(k) Number _