REQUEST FOR FDA 510K PROPOSALPlease enable JavaScript in your browser to complete this form.1. IMPORTANT INFORMATION - Step 1 of 6 Please fill out the FDA 510k request for proposal and submit it online for a comprehensive proposal. It’s crucial to realize that the precise and accurate information provided here will aid us in accurately estimating the budget.NEXTEstablishment Name *Establishment Type *ManufacturerSpecification DeveloperA specification developer develops the specifications for a finished device, but has the device manufactured under contract by another firm or entity. The specification developer submits the 510(k), not the contract manufacturer.Address *Address Line 1Address Line 2CityState / Province / RegionPostal Code--- Select country ---AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryWebsite / URLBACKNEXTRole of the 510k applicant *SelectDesign, Manufacture and DistributeDesign, Develop and Distribute but, manufactured in a different facilityRole of the I3CGLOBAL *SelectGuidance + 510K Preparation + e-Copy Conversion + US Agent + Q-Submission + Final Submission + Answering to FDA queriesGuidance + 510K Preparation + e-Copy Conversion + Q-Submission + Final Submission + Answering to FDA queriesGuidance + 510K Preparation + e-Copy ConversionGuidance + 510K Preparation510K GAP assessment510K GAP assessment + Guidance in Closing GAPS + e-Copy Conversion + US Agent + Q-Submission + Final SubmissionGAP Assessment Service proposal can be generated only after submission of full 510k file. Status of GMP *SelectQMSR / 21 CFR 820 / ISO 13485 ImplementedQMSR /21 CFR 820 (In Progress)QMSR/CFR820 + IEC 62304 ImplementedNo GMP / QMS ImplementedBACKNEXTName of the Medical Device *Type of Device *Active Device (Device Function on any kind of Power Source)Active Device with SoftwareNon Active DeviceSoftware Medical Device (SAMD)Implants / Partial ImplantsIn-Vito Diagnostic Device (IVD)OthersA specification developer develops the specifications for a finished device, but has the device manufactured under contract by another firm or entity. The specification developer submits the 510(k), not the contract manufacturer.FDA Product Code(s) *https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPCD/classification.cfmFDA Regulation Number(s) Predicative Device 510k Number(s)Check the database if you do not have it! https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMN/pmn.cfmDevice Class *SelectClass IClass IIClass IIINot SureIntended use of the device *What is the purpose of this Device?BACKNEXTDevice Brand / Trade NameNumber of Models to be covered in 510k *SelectONETWO1-51-101-201-401-1001-1000Major Difference between the Models *SelectChange in DesignDifference in the Measurement/SizeDifference in the ColorRaw Material / Construction Material DifferenceDifference in SoftwareSoftware Version DifferenceIntended useNA (Only One Model)Any Accessories included (packed/sold along with Device) *NIL012-33-5BACKNEXTSubmitter Name *Designation / Job Title *Phone *Email *BACKSubmit