Information Collection

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

IC 188971 under ICR 202110-0910-010 · OMB 0910-0396.

⚠️ Notice: This information collection may be referencing outdated material.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 0396_FDA_3455.pdf Form
3455 FDA Form 3455 0396_FDA_3455.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

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 54

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	0396_FDA_3455.pdf		Yes	Yes	Fillable Printable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 72	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	72	-33	105
Annual IC Time Burden (Hours)	360	-165	525
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.