Please respond to question 1, questions 2 and 3, OR question 4. Please read each carefully.

To obtain information regarding the clearance status of a device or pharmaceutical refer to the product labeling or call the FDA 1-800-638-2041 or visit the FDA internet site at http://www.fda.gov/cdrh/510khome.html.

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* 1. In my ‘work’ for this educational program or publication: the FDA has cleared all pharmaceuticals and/or medical devices for the use described in this presentation.

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* 2. In my ‘work’ for this educational program or publication: the FDA has not cleared the following pharmaceuticals and/or medical devices for the use described in this presentation. The following pharmaceuticals and/or medical devices are being discussed for an off-label use.

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* 3. If you agree with #2 above, enter the name of the drug(s)/device(s) and the manufacturer(s) here.

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* 4. In my ‘work’ for this educational program or publication: FDA clearance is not applicable

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* 5. Enter your full legal name including credentials. By typing your name, you attest that all information above is correct.

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* 6. Enter today's date in mm/dd/year format. Example: 04/14/2014

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