K Number
K140186
Device Name
THE STORK OTC
Date Cleared
2014-07-11

(168 days)

Product Code
Regulation Number
884.5250
AI/MLSaMDIVD (In Vitro Diagnostic)TherapeuticDiagnosticis PCCP AuthorizedThirdparty
Intended Use
The Stork® OTC is indicated for over-the-counter home use by couples who have been unable to conceive naturally and who have received a diagnosis of low sperm count, sperm immobility or unfavorable vaginal environment. The Stork® OTC contains a cervical cap inside a condom-like silicone sheath. It is used to collect semen into a cervical cap then deliver it to the outside of the cervix as an aid to conception. The Stork® OTC should be used during the ovulatory phase of the menstrual cycle. The Stork® OTC Cervical Cap should not be left in place for longer than six hours.
Device Description
The Stork® OTC package includes: one Instructions for Use, one Conceptacle® and one plastic applicator. Once the couple has decided to attempt to become pregnant, the Stork® OTC Conception System Instruction for Use recommends using the device during female's most fertile days in a given month. During sexual intercourse, semen will be collected using the Conceptacle®, a cervical cap that is pre-inserted into a condom-like sheath. The male removes the Conceptacle® from the penis by rolling it down and separating it from the penis. After removal, the rim of the cervical cap is lightly pinched so that the Condom-like Sheath can be separated. (The Cervical Cap and Condom-like Sheath are separated in two separate parts). The semen is contained in the cervical cap and its reservoir. The second component, the Applicator, is used for ease of transition of the Cervical Cap to the cervix. The applicator seals the Cervical Cap and contains the semen for transition through the vaginal tract, assisting the female in guiding the cap to the cervix and releasing the semen and the cap in front of the cervix. When the cervical cap is loaded onto the applicator (while it is still outside of the body), the Retainer locks onto the Cervical Cap and is delivered with the Cervical Cap intra-vaginally. The Retainer also has a removal cord that is attached for withdrawal. The Cervical Cap and Retainer then remain in place for up to 6 hours.
More Information

Not Found

No
The device description and performance studies focus on mechanical components and user interaction, with no mention of AI or ML technologies.

Yes
The device is intended to aid conception for couples experiencing specific fertility challenges (low sperm count, sperm immobility, or unfavorable vaginal environment) by facilitating the delivery of semen to the cervix, which is a therapeutic intervention.

No
The device is used to assist conception by collecting and delivering semen to the cervix, it does not diagnose any medical condition.

No

The device description clearly outlines physical components (cervical cap, condom-like sheath, plastic applicator, retainer, removal cord) and their physical interaction for semen collection and delivery. There is no mention of software as a component or function of the device.

Based on the provided information, the Stork® OTC is not an In Vitro Diagnostic (IVD) device.

Here's why:

  • IVD Definition: IVD devices are used to examine specimens (like blood, urine, or tissue) taken from the human body to provide information about a person's health, such as diagnosing a disease or monitoring a condition.
  • Stork® OTC Function: The Stork® OTC is a mechanical device designed to collect semen and deliver it to the cervix. It facilitates the physical process of conception by aiding sperm delivery. It does not analyze or test any biological sample to provide diagnostic information.
  • Intended Use: The intended use clearly states it is an "aid to conception" for couples with specific challenges, not a diagnostic tool to identify or measure substances in a sample.
  • Device Description: The description focuses on the physical components and how they are used to collect and deliver semen. There is no mention of any analytical or testing capabilities.

Therefore, the Stork® OTC falls under the category of a medical device that assists with a physiological process, rather than an IVD device that performs diagnostic testing on biological samples.

N/A

Intended Use / Indications for Use

The Stork® OTC is indicated for over-the-counter home use by couples who have been unable to conceive naturally and who have received a diagnosis of low sperm count. sperm immobility or unfavorable vaginal environment. The Stork® OTC contains a cervical cap inside a condom-like silicone sheath. It is used to collect semen into a cervical cap then deliver it to the outside of the cervix as an aid to conception. The Stork® OTC should be used during the ovulatory phase of the menstrual cycle. The Stork® OTC Cervical Cap should not be left in place for longer than six hours.

Product codes

OBB

Device Description

The Stork® OTC package includes: one Instructions for Use, one Conceptacle® and one plastic applicator. Once the couple has decided to attempt to become pregnant, the Stork® OTC Conception System Instruction for Use recommends using the device during female's most fertile days in a given month. During sexual intercourse, semen will be collected using the Conceptacle®, a cervical cap that is pre-inserted into a condom-like sheath. The male removes the Conceptacle® from the penis by rolling it down and separating it from the penis. After removal, the rim of the cervical cap is lightly pinched so that the Condom-like Sheath can be separated. (The Cervical Cap and Condom-like Sheath are separated in two separate parts). The semen is contained in the cervical cap and its reservoir. The second component, the Applicator, is used for ease of transition of the Cervical Cap to the cervix. The applicator seals the Cervical Cap and contains the semen for transition through the vaginal tract, assisting the female in guiding the cap to the cervix and releasing the semen and the cap in front of the cervix. When the cervical cap is loaded onto the applicator (while it is still outside of the body), the Retainer locks onto the Cervical Cap and is delivered with the Cervical Cap intra-vaginally. The Retainer also has a removal cord that is attached for withdrawal. The Cervical Cap and Retainer then remain in place for up to 6 hours.

Mentions image processing

Not Found

Mentions AI, DNN, or ML

Not Found

Input Imaging Modality

Not Found

Anatomical Site

vagincal tract, cervical os

Indicated Patient Age Range

Adult

Intended User / Care Setting

couples, home use

Description of the training set, sample size, data source, and annotation protocol

Not Found

Description of the test set, sample size, data source, and annotation protocol

Not Found

Summary of Performance Studies (study type, sample size, AUC, MRMC, standalone performance, key results)

A self-selection study and labeling comprehension study were performed to demonstrate that users could determine the uses of the device, the target population for device use, and if the labeling was clear and understandable. Additionally, a simulated use study was performed to verify that users could follow instructions under simulated-use conditions. All primary endpoints were achieved in all three sections of the study: Self-selection, labeling comprehension, and simulated use.

Following successful completion of the self-selection, labeling comprehension, and simulated use study and the finalization of labeling, clinical human factors and usability testing was performed to validate the instructions for use and demonstrate the proper use placement of and the safety of the device for users. All subjects were able to use the device to collect semen, effectively position and place the Conceptacle® in the vaginal tract using the applicator, and remove the cervical cap from the vaginal tract. These steps were successfully completed without any evidence of trauma or injury to the vaginal tract or cervical os. These endpoints were verified by visual inspection and physical examination by the primary investigator.

Biocompatibility Testing was performed on the device to support the applicator color changes from the predicate device. Testing demonstrated that the Stork® OTC materials are considered non-cytotoxic, non-irritating, and non-sensitizing. Colorant safety was deemed acceptable through additional Colorant Leachables Testing and a resulting Toxicological Risk Assessment of Extractable Chemicals. Bench testing demonstrated that the pull strength of the withdrawal cord was met for all systems tested and a shelf life study was performed to verify that all components of the Stork® OTC were shown to function properly and according to their design intent following a 6 month shelf life test. The Stork® OTC Conceptacle is identical to the predicate and data from the predicate device was used for the following aspects: Human Sperm Survival Assay (HSSA) and Condom Mechanical Testing.

Key Metrics (Sensitivity, Specificity, PPV, NPV, etc.)

Not Found

Predicate Device(s)

K112200

Reference Device(s)

Not Found

Predetermined Change Control Plan (PCCP) - All Relevant Information

Not Found

§ 884.5250 Cervical cap.

(a)
Identification. A cervical cap is a flexible cuplike receptacle that fits over the cervix to collect menstrual flow or to aid artificial insemination. This generic type of device is not for contraceptive use.(b)
Classification. Class II (performance standards).

0

Traditional 510(K) K140186 Pg. 1of 8 and the country of the states

TAB 2

The Stork® OTC

JUL 1 1 2014

510(K) SUMMARY - K140186 THE STORK® OTC

Sponsor:

Rinovum Women's Health, Inc. 300 Oxford Drive Suite 330 Monroeville, PA 15146

Applicant:

Andrew Zeltwanger Rinovum Women's Health, Inc. 300 Oxford Drive Suite 330 Monroeville, PA 15146

724-241-8934 Phone: Facsimile: 724-204-8141

Date Prepared: June 5, 2014

Proprietary Name: The Stork® OTC

Common Name: Conception Assistance Kit

Classification Name: Kit, Conception-Assist, Home Use (Product Code: OBB)

Classification Panel: Obstetrical/Gynecological

Regulation: 21 CFR § 884.5250, Cervical Cap

Manufacturer Device Name Predicate Devices: Rinovum Women's The Focus Touch® Health, Inc Conception System

510(k) Number K112200

Reason for Submission:

Description of Device

The Stork® OTC package includes: one Instructions for Use, one Conceptacle® and one plastic applicator.

New Indication for Over-The-Counter Use

Once the couple has decided to attempt to become pregnant, the Stork® OTC Conception System Instruction for Use recommends using the device during female's most fertile days in a given month. During sexual intercourse, semen will be collected using the Conceptacle®, a cervical cap that is

1

Traditional 510(K) K140186 Pg. 2 of 8

pre-inserted into a condom-like sheath. The male removes the Conceptacle® from the penis by rolling it down and separating it from the penis. After removal, the rim of the cervical cap is lightly pinched so that the Condom-like Sheath can be separated. (The Cervical Cap and Condom-like Sheath are separated in two separate parts). The semen is contained in the cervical cap and its reservoir. The second component, the Applicator, is used for ease of transition of the Cervical Cap to the cervix. The applicator seals the Cervical Cap and contains the semen for transition through the vaginal tract, assisting the female in guiding the cap to the cervix and releasing the semen and the cap in front of the cervix. When the cervical cap is loaded onto the applicator (while it is still outside of the body), the Retainer locks onto the Cervical Cap and is delivered with the Cervical Cap intra-vaginally. The Retainer also has a removal cord that is attached for withdrawal. The Cervical Cap and Retainer then remain in place for up to 6 hours.

Indications for Use

The Stork® OTC is indicated for over-the-counter home use by couples who have been unable to conceive naturally and who have received a diagnosis of low sperm count. sperm immobility or unfavorable vaginal environment. The Stork® OTC contains a cervical cap inside a condom-like silicone sheath. It is used to collect semen into a cervical cap then deliver it to the outside of the cervix as an aid to conception. The Stork® OTC should be used during the ovulatory phase of the menstrual cycle. The Stork® OTC Cervical Cap should not be left in place for longer than six hours.

Comparison between predicate and proposed device

The tables below compare the two devices:

PREDICATE DEVICE:PROPOSED DEVICE:
Focus Touch® Conception SystemThe Stork® OTC
MANUFACTURERRinovum Women's Health
(formerly Intimate bridge 2
Conception, Inc.)Same as K112200
510(k) NUMBERK112200K140186
REGULATION NUMBER884.5250 Cervical Cap:Same as K112200
FDA PRODUCT CODEOBBSame as K112200
CLASSIFICATIONIISame as K112200
PREDICATE DEVICE:PROPOSED DEVICE:
Focus Touch® Conception SystemThe Stork® OTC
INDICATIONS FOR USEThe Focus Touch™ Conception System is indicated for assisted insemination in instances where low sperm count, sperm immobility, or hostile vaginal environment has been diagnosed. The system (cervical cap in a condom-like silicone sheath) is used to collect semen into a cervical cap, and then deliver the cap to the outside of the cervix as an aid to conception. It is to be used at home following physician instruction. The Focus Touch Conception System should not be left in place for longer than 6 hours.The Stork® OTC is indicated for over-the-counter home use by couples who have been unable to conceive naturally and who have received a diagnosis of low sperm count, sperm immobility or unfavorable vaginal environment. The Stork® OTC contains a cervical cap inside a condom-like silicone sheath. It is used to collect semen into a cervical cap then deliver it to the outside of the cervix as an aid to conception. The Stork® OTC should be used during the ovulatory phase of the menstrual cycle. The Stork® OTC Cervical Cap should not be left in place for longer than six hours.
CONTRAINDICATIONS FOR USEThis product is not for use by those for which it is medically unsafe to have sexual intercourse or to become pregnant.Same as K112200
INTENDED ENVIRONMENT FOR USEPrescription Home Use DeviceOver the Counter (OTC) Home Use Device
PATIENT POPULATIONAdultSame as K112200

2

:

3

:

PREDICATE DEVICE:PROPOSED DEVICE:
Focus Touch® Conception
SystemThe Stork® OTC
TECHNOLOGYCervical Cap Insemination
with an applicator for delivery
and placement. A removal
string for cervical cap
withdrawal.Same as K112200
MATERIAL
Cervical CapLiquid Silicone Rubber (LSR)
10:1, Implant Grade, CuredSame as K112200
Condom SheathLiquid Silicone Rubber (LSR)
10:1, Implant Grade, CuredSame as K112200
RetainerAcetal CopolymerSame as K112200
ApplicatorAcetal CopolymerSame as K112200
Removal Cord TetherPolyester USP Suture
MaterialSame as K112200
BIOCOMPATIBILITYDevices met requirements of
ISO 10993-1: 2009 for
Sensitization, Cytotoxicity
and IrritationSame as K112200
STERILITYNon-sterileSame as K112200
PACKAGINGThe system can be
purchased packaged in a
quantity of one (1) or three
(3) systems per package.The system can be
purchased packaged in a
quantity of one (1)
SINGLE USEYesSame as K112200
CONDOM/CONCEPTACLE
(SEMEN COLLECTION)
SHEATH OUTSIDE
DIAMETER$1.378" +/-.046"$Same as K112200

·

:

·

. 1

4

Traditional 510(K) K140186 Pg. 5 of 8

PREDICATE DEVICE:PROPOSED DEVICE:
Focus Touch® Conception
SystemThe Stork® OTC
OVERALL LENGTH OF
CONDOM/
CONCEPTACLE7.429" +/-.120" (estimated
tolerance - overall length is
comprised of 3 separately
toleranced dimensions"Same as K112200
OVERALL CAP LENGTH
(WHEN CONCEPTACLE
IS SEPARATED FROM
CONDOM)1.67"±.010"Same as K112200
SEMEN RESERVOIR
DIMENSIONS.500±.010" diameter X
.800±.010" deepSame as K112200
REMOVAL CORD
LENGTHLoop positioned at 6.50" from
the Cap RimSame as K112200
DELIVERY DEVICE
LENGTH9.05"—9.45"Same as K112200
DELIVERY DEVICE
MAXIMUM INSERTABLE
OUTER DIAMETER0.984"Same as K112200
  • . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Technological Characteristics

Please refer to the comparison table above to see a listing of technological features between the new and predicate device. No new technologies were introduced; therefore, no new questions of safety or efficacy are raised.

.

5

Figure 1: The Stork® OTC Component Diagram

Image /page/5/Figure/3 description: The image shows two diagrams, one labeled "the Applicator" and the other "the Conceptacle." The applicator diagram shows a long, slender device with several labeled parts, including "Petals (open)," "Cap Holder," "Stem," "Cap Release," "Plunger Release," and "Plunger Tab." The conceptacle diagram shows a funnel-shaped object with labels pointing to the "Cervical Cap (Inside)" and "Condom (outside)." The diagrams appear to be illustrating the components of a medical or contraceptive device.

Indication for Use Comparison

The indications for use between the predicate and proposed device differ in that the proposed device is indicated for over-the-counter use of the device rather than prescription use. The indication for use includes the same user group as the predicate, having the diagnoses of low sperm count, sperm immobility or unfavorable vaginal environment. It also includes further specification for users that have not been able to successfully conceive naturally. Further, the device labeling includes the same warnings and precautions. Studies were completed to demonstrate that the over-the-counter user population could sufficiently self-select and comprehend the labeling. The usability and safety clinical trial demonstrated that users could effectively and safely use the device without physician instruction, overview or intervention, and in accordance with the instructions for use. Therefore, the differences between the indications for use do not represent a new Intended Use. Nor do these differences present new concerns of safety and efficacy.

Performance Testing - Clinical

A self-selection study and labeling comprehension study were performed to demonstrate that users could determine the uses of the device, the target population for device use, and if the labeling was clear and understandable. Additionally, a simulated use study was performed to verify that users could follow instructions under simulated-use conditions. All primary endpoints were achieved in all three sections of the study: Self-selection, labeling comprehension, and simulated use.

Following successful completion of the self-selection, labeling comprehension, and simulated use study and the finalization of labeling, clinical human factors and usability testing was performed to validate the instructions for use and demonstrate the proper use placement of

6

Traditional 510(K) K140186 Pg. 7 of 8

and the safety of the device for users. All subjects were able to use the device to collect semen, effectively position and place the Conceptacle® in the vaginal tract using the applicator, and remove the cervical cap from the vaginal tract. These steps were successfully completed without any evidence of trauma or injury to the vaginal tract or cervical os. These endpoints were verified by visual inspection and physical examination by the primary investigator.

Primary Self-Selection and Labeling Comprehension Endpoints:

  • Understanding the Indications for Use .
  • Understanding the Selection of the Device
  • Understanding the Contraindications for Use
  • Understanding Warnings �
  • . Understanding When to Use the Device
  • Understanding Activity Limitations While Wearing the Cervical Cap ●
  • Understanding that the Device Does Not Guarantee Pregnancy .
  • Understanding How Long To Use the Device Without Successful Results Before Contacting a Physician

Primary Simulated Use / Usability Endpoints (Male):

  • Correctly Place the Conceptacle on a Penis .
  • Correctly Remove the Conceptacle from a Penis
  • Correctly Separate the Condom from the Cervical Cap .
  • Collect and Contain Semen Using the Conceptacle (Usability only)

Primary Simulated Use / Usability Endpoints (Female):

  • Correctly Place the Cervical Cap in the Applicator .
  • Correctly Close the Applicator ●
  • Correctly Insert the Applicator into a Vaqinal Tract .
  • Correctly Position the Applicator Near the Cervical Os .
  • Correctly Open the Cervical Cap with the Applicator .
  • Correctly Engage the Trigger Button to Release the Cervical Cap .
  • Leave the Cap in Place as Directed (Usability only) ●
  • Correctly Avoid Sexual Activity While the Cervical Cap is in Place (Usability only) .
  • Correctly Withdraw Device from the Vaginal Tract .
  • Correctly Treat the Device as Single Use .

Performance Testing - Bench

Biocompatibility Testing was performed on the device to support the applicator color changes from the predicate device. Testing demonstrated that the Stork® OTC materials are considered non-cytotoxic, non-irritating, and non-sensitizing. Colorant safety was deemed acceptable through additional Colorant Leachables Testing and a resulting Toxicological Risk Assessment of Extractable Chemicals. Bench testing demonstrated that the pull strength of the withdrawal cord was met for all systems tested

7

The Stork® OTC

Traditional 510(K) K140186 Pg. 8 of 8

and a shelf life study was performed to verify that all components of the Stork® OTC were shown to function properly and according to their design intent following a 6 month shelf life test. The Stork® OTC Conceptacle is identical to the predicate and data from the predicate device was used for the following aspects:

  • . Human Sperm Survival Assay (HSSA)
  • Condom Mechanical Testing .
  • Shelf-life ◆

Conclusions

The Stork® OTC is substantially equivalent to the Focus Touch® Conception System. The Stork® OTC has the same intended uses, technological characteristics, and principles of operation as its predicate device. The differences between The Stork® OTC and the Focus Touch® Conception System raise no new issues of safety or effectiveness. Usability and Clinical data demonstrate that The Stork® OTC is as safe and effective as the Focus Touch®. Thus, The Stork® OTC is substantially equivalent.

8

Image /page/8/Picture/1 description: The image shows the logo for the U.S. Department of Health and Human Services. The logo consists of a stylized caduceus symbol, which is a staff with two snakes coiled around it. The text "DEPARTMENT OF HEALTH & HUMAN SERVICES - USA" is arranged in a circular fashion around the caduceus symbol. The logo is black and white.

Food and Drug Administration 10903 New Hampshire Avenue Document Control Center - WO66-G609 Silver Spring, MD 20993-0002

July 11, 2014

Rinovum Women's Health, Inc. Andrew Zeltwanger Director of Regulatory & Quality 300 Oxford Drive, Suite 330 Monroeville, PA 15146

Re: K140186

Trade/Device Name: The Stork® OTC Regulation Number: 21 CFR§ 884.5250 Regulation Name: Cervical Cap Regulatory Class: II Product Code: OBB Dated: June 10, 2014 Received: June 11, 2014

Dear Andrew Zeltwanger,

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. Please note: CDRH does not evaluate information related to contract liability warranties. We remind you, however, that device labeling must be truthful and not misleading.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to 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.

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.

9

Page 2 - Andrew Zeltwanger

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); medical device reporting (reporting of medical device-related adverse events) (21 CFR 803); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act): 21 CFR 1000-1050.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please go to http://www.fda.gov/AboutFDA/CentersOffices/CDRHOffices/ucm115809.htm for the Center for Devices and Radiological Health's (CDRH's) Office of Compliance. Also, please note the regulation entitled, "Misbranding by reference to premarket notification" (21CFR Part 807.97). For questions regarding the reporting of adverse events under the MDR regulation (21 CFR Part 803), please go to

http://www.fda.gov/MedicalDevices/Safety/ReportaProblem/default.htm for the CDRH's Office of Surveillance and Biometrics/Division of Postmarket Surveillance.

You may obtain other general information on your responsibilities under the Act from the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number (800) 638-2041 or (301) 796-7100 or at its Internet address http://www.fda.gov/MedicalDevices/Resourcesfor You/Industry/default.htm.

Sincerely yours.

GlenBell-S

for

Benjamin R. Fisher, Ph.D. Director Division of Reproductive, Gastro-Renal, and Urological Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

10

DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration

Indications for Use

510(k) Number (if known) K140186

Device Name The Stork® OTC

Indications for Use (Describe)

The Stork® OTC is indicated for over-the-counter home been unable to conceive naturally and who have received a diagnosis of low sperm immobility or unfavorable vaginal environment. The Stork® OTC contains a cervical cap inside a condom-like silicone sheath. It is used to collect semen into a cervical cap the cervix as an aid to conception. The Stork® OTC should be used during the ovulatory phase of the Stork® OTC Cervical Cap should not be left in place for longer than six hours.

Type of Use (Select one or both, as applicable)Prescription Use (Part 21 CFR 801 Subpart D) ☑Over-The-Counter Use (21 CFR 801 Subpart C)Prescription Use (Part 21 CFR 801 Subpart D)☑ Over-The-Counter Use (21 CFR 801 Subpart C)
Prescription Use (Part 21 CFR 801 Subpart D)
☑ Over-The-Counter Use (21 CFR 801 Subpart C)

PLEASE DO NOT WRITE BELOW THIS LINE - CONTINUE ON A SEPARATE PAGE IF NEEDED.

FOR FDA USE ONLY

Concurrence of Center for Devices and Radiological Health (CDRH) (Signature)for Ben R Fisher
------------------------------------------------------------------------------------------------

Glenn B. Bell -S

FORM FDA 3881 (1/14)Page 1 of 2
PSC Publishing Services (301) 443-6740 EF
1-3

Form Approved: OMB No. 0910-0120 Expiration Date: January 31, 2017 See PRA Statement on last page.

11

This section applies only to requirements of the Paperwork Reduction Act of 1995.

DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF EMAIL ADDRESS BELOW.

The burden time for this collection of information is estimated to average 79 hours per response, including the time to review instructions, search existing data sources, gather and maintain the data needed and complete and review the collection of information. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden, to:

Department of Health and Human Services Food and Drug Administration Office of Chief Information Officer Paperwork Reduction Act (PRA) Staff PRAStaff@fda.hhs.gov

"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 number."