Food and Drug Administration
Office of Device Evaluation &
Office of In Vitro Diagnostics
COVER SHEET MEMORANDUM
From: Reviewer Name ______________________________________________
Subject: 510(k) Number ______________________________________________
To: The Record
Please list CTS decision code _____________
- Refused to accept (Note: this is considered the first review cycle, See Screening Checklist
- Hold (Additional Information or Telephone Hold).
- Final Decision (SE, SE with Limitations, NSE, Withdrawn, etc.).
Please complete the following for a final clearance decision (i.e., SE, SE with Limitations, etc.): |
YES |
NO |
||
Indications for Use Page |
Attach IFU |
|
|
|
510(k) Summary /510(k) Statement |
Attach Summary |
|
|
|
Truthful and Accurate Statement. |
Must be present for a Final Decision |
|
|
|
Is the device Class III? If yes, does firm include Class III Summary? |
Must be present for a Final Decision |
|
|
|
Does firm reference standards? |
|
|
||
Is this a combination product? |
|
|
||
Is this a reprocessed single use device? |
|
|
||
Is this device intended for pediatric use only? |
|
|
||
Is this a prescription device? (If both prescription & OTC, check both boxes.) |
|
|
||
Is clinical data necessary to support the review of this 510(k)? |
|
|
||
Does this device include an Animal Tissue Source? |
|
|
||
Is this device subject to Section 522 Postmarket Surveillance? |
Contact OSB. |
|
|
|
Is this device subject to the Tracking Regulation? (Medical Device Tracking Guidance) |
Contact OC. |
|
|
Regulation Number | Class* | Product Code |
__________________________________________________________________________________
(*If unclassified, see 510(k) Staff)
Additional Product Codes:__________________________________________________________
Review:____________________________________________________________________________
(Branch Chief) |
(Branch Code) |
(Date) |
Final Review:______________________________________________________________________
(Division Director) |
(Date) |
Updated July 30, 2007
CDRH Home Page | CDRH A-Z Index | Contact CDRH | Accessibility | Disclaimer
FDA Home Page | Search FDA Site | FDA A-Z Index | Contact FDA | HHS Home Page
Center for Devices and Radiological Health / CDRH