Certification--54.4(a)(1) and (a)(2)--Form FDA 3454

Financial Disclosure by Clinical Investigators

Documents and Forms

Document Name Document Type
Form 3454 Certification--54.4(a)(1) and (a)(2)--Form FDA 3454 Form
3454 FDA Form 3454 0396_FDA_3454.pdf Form
3454 FDA Form 3454 0396_FDA_3454.pdf Form

Information Collection (IC) Details

IC Title:	Certification--54.4(a)(1) and (a)(2)--Form FDA 3454	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation: 21 CFR 54.4

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	3454	FDA Form 3454	0396_FDA_3454.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 715	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	715	-335	1,050
Annual IC Time Burden (Hours)	715	-335	1,050
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.