Form 3429 FDA Form 3429

DEPARTMENT OF HEALTH AND HUMAN SERVICES
PUBLIC HEALTH SERVICE --- FOOD AND DRUG ADMINISTRATION

FORM APPROVED: OMB NO. 0910-0138
EXPIRATION DATE: June 30, 2018
(See PRA Statement on Page 2)

GENERAL DEVICE CLASSIFICATION QUESTIONNAIRE
PANEL MEMBER/PETITIONER

DATE

GENERIC TYPE OF DEVICE

CLASSIFICATION RECOMMENDATION

1. IS THE DEVICE LIFE-SUSTAINING OR LIFE-SUPPORTING ?

YES

NO

2. IS THE DEVICE FOR A USE WHICH IS OF SUBSTANTIAL IMPORTANCE IN
PREVENTING IMPAIRMENT OF HUMAN HEALTH ?

YES

NO

3. DOES THE DEVICE PRESENT A POTENTIAL UNREASONABLE RISK OF ILLNESS
OR INJURY ?

YES

NO

4. IS THERE SUFFICIENT INFORMATION TO DETERMINE THAT GENERAL
CONTROLS ARE SUFFICIENT TO PROVIDE REASONABLE ASSURANCE OF
SAFETY AND EFFECTIVENESS ?

YES

NO

YES

NO

5. IS THERE SUFFICIENT INFORMATION TO ESTABLISH SPECIAL CONTROLS IN
ADDITION TO GENERAL CONTROLS TO PROVIDE REASONABLE ASSURANCE
OF SAFETY AND EFFECTIVENESS ?
6. IF THERE IS SUFFICIENT INFORMATION TO ESTABLISH SPECIAL CONTROLS TO
PROVIDE REASONABLE ASSURANCE OF SAFETY AND EFFECTIVENESS, IDENTIFY
BELOW THE SPECIAL CONTROL(S) NEEDED TO PROVIDE SUCH REASONABLE
ASSURANCE. FOR CLASS II.
Guideline Document
Performance Standard(s)
Device Tracking
Testing Guidelines
Other (Specify)

7. IF A REGULATORY PERFORMANCE STANDARD IS NEEDED TO PROVIDE
REASONABLE ASSURANCE OF THE SAFETY AND EFFECTIVENESS OF A CLASS II
OR III DEVICE, IDENTIFY THE PRIORITY FOR ESTABLISHING SUCH A STANDARD.
Low Priority
Medium Priority
High Priority
Not Applicable
8. FOR A DEVICE RECOMMENDED FOR RECLASSIFICATION INTO CLASS II,
SHOULD THE RECOMMENDED REGULATORY PERFORMANCE STANDARD BE IN
PLACE BEFORE THE RECLASSIFICATION TAKES EFFECT ?

YES

NO

NOT Applicable
9. FOR A DEVICE RECOMMENDED FOR CLASSIFICATION/RECLASSIFICATION INTO
CLASS III, IDENTIFY THE PRIORITY FOR REQUIRING PREMARKET APPROVAL
APPLICATION (PMA) SUBMISSIONS.

Low

Priority

Medium

Priority

High

Priority

Not Applicable

FORM FDA 3429 (7/12)

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PSC Publishing Services (301) 443-6740

EF

10. IDENTIFY THE NEEDED RESTRICTION(S)
Only upon the written or oral authorization of a practitioner licensed by law to
administer or use the device
Use only by persons with specific training or experience in its use
Use only in certain facilities
Other (Specify)

11. COMPLETE THIS FORM PURSUANT TO 21 CFR PART 860 AND SUBMIT TO:

Food and Drug Administration
Center for Devices and Radiological Health
Office of the Center Director
Regulations Staff, WO66-4436
10903 New Hampshire Avenue
Silver Spring, MD 20993-0002

This section applies only to requirements of the Paperwork Reduction Act of 1995.
Please see item 11 for the address to which you may send your completed form.
*DO NOT SEND YOUR COMPLETED FORM TO THE PRA STAFF ADDRESS BELOW.*

The burden time for this collection of information is estimated to average 500 hours per response, including the time to review instructions,
search existing data sources, gather and maintain the data needed and complete and review the collection of information. Send comments
regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden, to:
Department of Health and Human Services
Food and Drug Administration Office
of Chief Information Officer
Paperwork Reduction Act (PRA) Staff
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 3429 (7/12)

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INSTRUCTIONS FOR GENERAL DEVICE QUESTIONNAIRE
1.

Answer each question by checking yes or no in the right column. The preparer should refer to
Title 21 Part 860 of the Code of Federal Regulations for classification/reclassification definitions
and procedures.

2.

The General Device questionnaire is designed to aid in the determination of the proper class for
all medical devices.

3.

A medical device should be placed in the lowest class which will provide adequate controls to
reasonably assure the safety and effectiveness of the device.

4.

Questions 1, 2, and 3 pertain to the degree of risk of the device and can be answered broadly.

5.

Question 6 is applicable only to devices recommended for class II.

6.

Questions 7 & 8 are not applicable unless a regulatory standard, subject to section 514 of the
Food, Drug, and Cosmetic Act, as amended, 1976, has been designated as a "special control."

7.

Question 9 is applicable only to devices recommended for class III.

8.

Question 10 refers to restriction such as prescription use or similar limitations as to the use of the
device.

9.

Use this completed questionnaire to prepare the Supplemental Data Sheet. Send both forms to
the address indicated in item 11.

FORM FDA 3429 (7/12)

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