Certification of Identity; Form FDA 3975

Certification of Identity for Freedom of Information and Privacy Act Requests

Documents and Forms

Document Name Document Type
Form FDA 3975 Certification of Identity; Form FDA 3975 Form and Instruction
FDA 3975 Certification of Identify FDA-3975_06-23-20-Secured (2).pdf Form and Instruction
FDA 3975 Certification of Identify FDA-3975_06-23-20-Secured (2).pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Certification of Identity; Form FDA 3975	Agency IC Tracking Number:	ORA

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation: 21 CFR 20 and 21

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	FDA 3975	Certification of Identify	FDA-3975_06-23-20-Secured (2).pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title: (SORN) 09-90-0058	FR Citation: 81 FR 17463

Number of Respondents: 24	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 70 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	24	-26	50
Annual IC Time Burden (Hours)	4	-5	9
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.