Form 3455 FDA Form 3455

DEPARTMENT OF HEALTH AND HUMAN SERVICES Food and Drug Administration DISCLOSURE: FINANCIAL INTERESTS AND ARRANGEMENTS OF CLINICAL INVESTIGATORS	Form Approved: OMB No. 0910-0396 Expiration Date: August 31, 2012
TO BE COMPLETED BY APPLICANT
The following information concerning , who participated Name of clinical investigator as a clinical investigator in the submitted study Name of is submitted in accordance with 21 CFR part 54. The clinical study 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.
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 5 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

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FORM FDA 3455 (7/12)

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