Form 2567 Transmittal of Labels and Circulars

General Licensing Provisions: Biologics License Application, Changes to an Approved Application, Labeling, Revocation and Suspension, and Forms FDA 356h & 2567

FORM 2567 11-5-13

601.12(c)(5) - Changes to an Approved Application

OMB: 0910-0338

Document [pdf]
Download: pdf | pdf
Form Approved; OMB No. 0910-0338.
Expiration Date: December 31, 2013
See OMB statement on reverse.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
FOOD AND DRUG ADMINISTRATION
CENTER FOR BIOLOGICS EVALUATION AND RESEARCH

TRANSMITTAL OF LABELS AND CIRCULARS

1. LABEL REVIEW NO. AND REVISION

2. CHECK ONE

Draft

Final (in distribution)

NOTE: No license may be granted unless this completed submittal form has been received (U.S. Public Health Service Act, Section 351; the
Federal Food, Drug, and Cosmetic Act, Section 502; and Title 21 U.S. Code of Federal Regulations, Part 600).
3.

6.

7.

4. LICENSE NO.

MANUFACTURER NAME
AND RETURN
ADDRESS

5. REGISTRATION NO.

PRODUCT
NAME
LABEL TYPE CODE
(see below)

LABELING
DETAILS

8. SUBMISSION REASONS (Check all that apply)

REPLACES PREVIOUS LABEL
REVIEW & REVISION NO.
DATE

New Product
New Indication

LABEL TYPE CODES
(select only one)
CIRC
CONT
PACK

9.

Circular
Container
Package

DILT
BLST
CRTN

Diluent
Blister
Carton

PCKR
SHIP
BULK
OTHR

CHECK THE BOX(es) INDICATING FORMAT OF
THIS SUBMISSION (More than one may be checked.)

10. CHECK BOX IF THIS LABELING
IS IN SUPPORT OF:

Dosage Change

Application

Packer
Shipping
Bulk
Other (Specify in
Comments)

Manufacturing
Method Change
Anticoagulant /
Additive Change

Paper

Electronic

Supplement

Part of an Annual
Report

New Scientific
Information
Editorial, Format
Contraindications,
Adverse Reactions,
Precautions
New Formulation
Other (Specify in
Comments)

Associated BLA /PLA No.

11. COMMENTS (Include any Manuf. ID number, description or revision no. of label being replaced. IF FINAL PRINTED, provide LOT NO. & DATE of
FIRST USE.)

12.

AUTHORIZED
OFFICIAL

SIGNATURE

DATE

THE SPACES BELOW ARE FOR USE BY CENTER FOR BIOLOGICS EVALUATION AND RESEARCH

COMMENTS (See attached comments

REVIEWED BY
RETURNED BY
FORM FDA 2567 (1/11)

)

SIGNATURE

DATE

SIGNATURE

DATE
PREVIOUS EDITION IS OBSOLETE.

FRONT
PSC Publishing Services (301) 443-6740

EF

GENERAL INSTRUCTIONS FOR COMPLETING FORM FDA 2567
Type or print legibly in ink. Submit three copies of preliminary proofs and drafts. For revised labeling, indicate where changes
have been made on the labeling copy. Assemble and staple each set, including attachments. Submit each type of labeling
(carton, container, insert, etc.) with a Form FDA 2567. The transmittal form should be dated and signed by the authorized
official. Send to the Food and Drug Administration, Center for Biologics Evaluation and Research (CBER), HFM-99, 1401
Rockville Pike, Rockville, Maryland 20852-1448. Either Form FDA 2567 or Form FDA 2253 may be used for submissions of
advertising and promotional labeling. Send to the above address and reference the mail code HFM-602.

INSTRUCTIONS FOR COMPLETING NUMBERED ITEMS ON FORM FDA 2567
1.

If this is the initial submission for a new or revised label, leave blank and FDA will assign a number. If this is a resubmission
of pending labeling, you may include the previously assigned number.

2.

Check the draft box if this is a revised draft or a final draft label. Check the final box if item is final printed labeling that has
been distributed.

3.

Enter the manufacturer’s name and complete address where the review comments should be returned.

4.

If establishment is licensed, enter license number.

5.

Enter the registration number that will appear on the label for blood and blood components for submissions that are directed
to the Office of Blood Research and Review. This field should be left blank for other product submissions.

6.

Enter the proper name (e.g. established or United States Adopted Name) followed by the trade name, if any, for the product.

7.

For LABEL TYPE CODE , select only ONE label type and enter into the box. Multiple labels may be submitted under each
Form 2567 although all must be of the same type and product. Each label type requires an additional form. For REVIEW
AND REVISION NO., if Form 2567 applies to an initial submission or revised labeling submitted under 21 CFR 601.12,
complete the REPLACES PREVIOUS LABEL box with the most recent marketed labeling of this type and the date it was
returned by CBER. If form applies to a resubmission of pending labeling and the FDA has already assigned this number,
complete the box with revision number indicated on the copy of the Form 2567 that FDA returned to company, and the date
FDA signed the REVIEWED BY date box. The REPLACES PREVIOUS LABEL boxes do not apply to labeling for brand
new products.

8.

Check the box that best applies to your current submission. The Anticoagulant/Additive Change applies only to submissions
directed to the Office of Blood Research and Review.

9.

Check the applicable box(es). If any part of the labeling is on diskette, CD, or other electronic media, the electronic box
should be checked.

10.

Check one of the boxes if this labeling is associated with or in support of an original application, supplement, or annual
report and enter the reference or submission tracking number in the Associated BLA/PLA No. box.

11.

Complete with any comments that are important for the review, including manufacturer ID number(s), description or revision
numbers of labels being replaced, submission reason not covered in checklist in item number 8, label type code not included
in item number 7, etc. If this is FINAL LABELING that has been distributed, provide the lot number and the date of
distribution in this space.

12.

An authorized official signs his/her name in this space followed by the date that the labeling is being submitted to CBER.

Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and 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:
Department of Health and Human Services
Food and Drug Administration
Office of Chief Information Officer
1350 Piccard Drive, Room 400
Rockville, MD 20850
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.
FORM FDA 2567 (1/11)

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File Typeapplication/pdf
File TitleFDA-2567
SubjectDepartment of Health and Human Services..Food and Drug Administration..Center for Biologics Evaluation and Research
File Modified2011-03-08
File Created2007-07-19

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