Disclosure--54.4(a)(3)--Form FDA 3455

Financial Disclosure by Clinical Investigators

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0396 can be found here:

Documents and Forms

Document Name Document Type
Form 3455 Disclosure--54.4(a)(3)--Form FDA 3455 Form
3455 FDA Form 3455 FDA 3455 exp 12-31-15.pdf Form

Information Collection (IC) Details

IC Title:	Disclosure--54.4(a)(3)--Form FDA 3455	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 21 CFR 301

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	3455	FDA Form 3455	FDA 3455 exp 12-31-15.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 10 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	100	10	90
Annual IC Time Burden (Hours)	500	50	450
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.