GLOVETEX POWDER FREE NITRILE EXAMINATION GLOVES, BLUE, NON-STERILE

K032010 · Pt. Wrp Buana Multicorpora · LZA · Aug 19, 2003 · General Hospital

Device Facts

• Record ID: K032010
• Device Name: GLOVETEX POWDER FREE NITRILE EXAMINATION GLOVES, BLUE, NON-STERILE
• Applicant: Pt. Wrp Buana Multicorpora
• Product Code: LZA · General Hospital
• Decision Date: Aug 19, 2003
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 880.6250
• Device Class: Class 1

Intended Use

The Powder Free Nitrile Examination Glove, Blue, Non Sterile is a disposable device intended for medical purposes that is worn on the examiner's hand to prevent contamination between patient and examiner.

Device Story

Disposable nitrile synthetic rubber examination gloves; non-sterile; blue color. Worn by healthcare professionals on hands or fingers during patient examinations. Primary function is barrier protection to prevent cross-contamination between patient and examiner. Device is used in clinical settings. No complex processing or electronic components.

Clinical Evidence

No clinical data. Substantial equivalence is supported by non-clinical bench testing, including dimensions, physical properties, freedom from pinholes (ASTM D 6319-00ae3, FDA 21 CFR 800.20), powder-free residue (ASTM D 6124-01), and biocompatibility (primary skin irritation and dermal sensitization).

Technological Characteristics

Material: Nitrile synthetic rubber. Standards: ASTM D 6319-00ae3 (dimensions, physical properties), ASTM D 6124-01 (powder residue). Testing: FDA 1000 ml water leak test, primary skin irritation, dermal sensitization. Form factor: Disposable, non-sterile, blue examination glove.

Indications for Use

Indicated for use as a disposable medical glove worn on the examiner's hand or finger to prevent cross-contamination between patient and examiner.

Regulatory Classification

Identification

A non-powdered patient examination glove is a disposable device intended for medical purposes that is worn on the examiner's hand or finger to prevent contamination between patient and examiner. A non-powdered patient examination glove does not incorporate powder for purposes other than manufacturing. The final finished glove includes only residual powder from manufacturing.

Submission Summary (Full Text)

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Image /page/0/Picture/0 description: The image shows the text "PT. WRP Buana Multicorpora" in bold, black font. The text appears to be the name of a company. The text is horizontally aligned and takes up most of the image space. The background is plain white.

K03 2010

Jalan Jermal No. 20-B, Kelurahan Sei Mati, Medan-Labuhan Km 17, INDONESIA

| Tel | + 62-61-6942461 |
|-----|------------------|
| | + 62-61-6942462 |
| Fax | + 62-61-6942463 |
| URL | www.wrpworld.com |

:

AUG 1 9 2003

# 510 (K) SUMMARY

### 1.0 Submitter :

| Name | : PT. WRP Buana Multicorpora |
|-----------|---------------------------------------------------------------------------|
| Address | : Jl. Jermal No.20B Kelurahan Sei Mati<br>Medan Labuhan KM 17, INDONESIA. |
| Phone No. | : [phone], 6942462 |
| Fax No. | : [phone] |

Date of Summary Prepared : 29 July, 2003

### 2.0 Contact Person :

| Name | : Mr. Ng Poy Sin |
|-----------|--------------------------|
| Phone No. | : [phone], 6942462 |
| Fax No. | : [phone] |

### 3.0 Name of the device :

| Trade Name | 1). Glovetex, and |
|---------------------|-----------------------------------------------------------|
| | 2). Multiple or Customers' Trade Name |
| Device Name | Powder Free Nitrile Examination Gloves, Blue, Non-Sterile |
| Common Name | Examination Gloves |
| Classification Name | Patient Examination Gloves (Class I) |

### 4.0 ldentification of The Legally Marketed Device :

Class I patient examination gloves, 80LZA, powdered, that meets all the requirements of ASTM standard D 6319 – 00a83 and FDA 1000 ml Water Leak Test.

#### 5.0 Description of The Device :

The Powder Free Nitrile Examination Gloves, Blue, Non Sterile meets all the requirements of ASTM standard D 6319 – 00a83 and FDA 1000 ml Water Leak Test.

#### 6.0 Intended Use of the Device :

The Powder Free Nitrile Examination Glove, Blue, Non Sterile is a disposable device intended for medical purposes that is worn on the examiner's hand to prevent contamination between patient and examiner.

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## RP Buana Multicorpora

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Jalan Jermal No. 20-B, Kelurahan Sei Mati, Medan-Labuhan Km 17, INDONESIA

Tel [phone] [phone] Fax [phone] URL www.wrpworld.com

### 7.0 Summary of The Technological Characteristics of The Device :

The Powder Free Nitrile Latex Examination Gloves, Blue, Non Sterile are summarized with the following technological characteristics compared to ASTM or equivalent standards.

| CHARACTERISTICS | STANDARDS | DEVICE<br>PERFORMANCE |
|-----------------------|---------------------------------------|----------------------------------------|
| Dimensions | D 6319 - 00ae3 | Meets |
| Physical Properties | D 6319 - 00ae3 | Meets |
| Freedom from Pinholes | D 6319 - 00ae3<br>FDA 21 CFR 800.20 | Meets |
| Powder Free Residue | D 6124 - 01 | Meets<br>< 2mg/ glove |
| Biocompatability | Primary Skin Irritation in<br>Rabbits | Passes<br>(No primary skin irritation) |
| | Dermal Sensitization | Passes<br>(No contact sensitizer) |

### 8.0 Substantial Equivalent Based on Assessment of Non-Clinical Performance Data

The performance test data of the non-clinical tests that support a determination of substantial equivalent is the same as mentioned immediately above.

### 9.0 Substantial Equivalent Based on Assessment of Clinical Performance Data

Clinical data is not needed for gloves or for most devices cleared by the 510(k) process.

### 10.0 Conclusion

It can be concluded that the Powder Free Nitrile Examination Gloves, Blue, Non Sterile will perform according to the glove performance standards referenced in Section (7) above and meet ASTM standards, and FDA requirements for water leak test on pinhole AQL. Consequently, this device is substantially equivalent to currently marketed devices.

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Public Health Service

AUG 1 9 2003

Food and Drug Administration 9200 Corporate Boulevard Rockville MD 20850

PT. WRP Buana Multicorpora Mr. Ng Pov Sin President Director Jalan Jermal No. 20-B, Kelurahan Sei Mati Medan- Labuhan Km 17, INDONESIA

Re: K032010

Trade/Device Name: Powder Free Nitrile Examination Glove, Blue, Non- Sterile Regulation Number: 880.6250 Regulation Name: Patient Examination Glove Regulatory Class: I Product Code: LZA Dated: July 30, 2003 Received: August 4, 2003

Dear Mr. Sin:

We have reviewed your Section 510(k) premarket notification of intent to market the device referenced above and have determined the device is substantially equivalent (for the indications for use stated in the enclosure) to legally marketed predicate devices marketed in interstate commerce prior to May 28, 1976, the enactment date of the Medical Device Amendments, or to devices that have been reclassified in accordance with the provisions of the Federal Food, Drug, and Cosmetic Act (Act) that do not require approval of a premarket approval application (PMA). You may, therefore, market the device, subject to the general controls provisions of the Act. The general controls provisions of the Act include requirements for annual registration, listing of devices, good manufacturing practice, labeling, and prohibitions against misbranding and adulteration.

If your device is classified (see above) into either class II (Special Controls) or class III (PMA), it may be subject to such additional controls. Existing major regulations affecting your device can be found in the Code of Federal Regulations, Title 21, Parts 800 to 898. In addition, FDA may publish further announcements concerning your device in the Federal Register.

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### Page 2 - Mr. Sin

Please be advised that FDA's issuance of a substantial equivalence determination does not mean that FDA has made a determination that your device complies with other requirements of the Act or any Federal statutes and regulations administered by other Federal agencies. You must comply with all the Act's requirements, including, but not limited to: registration and listing (21 CFR Part 807); labeling (21 CFR Part 801); good manufacturing practice requirements as set forth in the quality systems (QS) regulation (21 CFR Part 820); and if applicable, the electronic product radiation control provisions (Sections 531-542 of the Act); 21 CFR 1000-1050.

This letter will allow you to begin marketing your device as described in your Section 510(k) premarket notification. The FDA finding of substantial equivalence of your device to a legally marketed predicate device results in a classification for your device and thus, permits your device to proceed to the market.

If you desire specific advice for your device on our labeling regulation (21 CFR Part 801), please contact the Office of Compliance at [phone]. Also, please note the regulation entitled. "Misbranding by reference to premarket notification" (21CFR Part 807.97). You may obtain other general information on your responsibilities under the Act from the Division of Small Manufacturers, International and Consumer Assistance at its toll-free number [phone] or [phone] or at its Internet address http://www.fda.gov/cdrh/dsma/dsmamain.html

Sincerely vours.

Susan Runne

Susan Runner, DDS, MA Interim Director Division of Anesthesiology, General Hospital, Infection Control and Dental Devices Office of Device Evaluation Center for Devices and Radiological Health

Enclosure

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Image /page/4/Picture/0 description: The image shows a black logo with the letters "WRP" in white. The letters are bold and sans-serif. The logo is in the shape of a rounded rectangle with slightly pointed corners. The background is black, and the letters are white, creating a high contrast.

Jalan Jermal No. 20-B, Kelurahan Sei Mati, Medan-Labuhan Km 17, INDONESIA

Tel + 62-61 -6942461 + 62-61-6942462 + 62-61-6942463 Fax URL www.wrpworld.com

### INDICATIONS FOR USE

| Applicant | : PT. WRP Buana Multicorpora |
|----------------------------|----------------------------------------------------------------|
| 510(k) Number (if known) : | K032010 |
| Device Name | : POWDER FREE NITRILE<br>EXAMINATION GLOVES, BLUE, NON STERILE |

Indications For Use:

Powder Free Nitrile Examination Gloves, Blue, Non-Sterile is a disposable device and made of Synthetic Rubber intended for medical purposes that is worn on the examiner's hand or finger to prevent contamination between patient and examiner.

Concurrence of CDRH, Office of Device Evaluation (ODE)

Clins S. Lam

(Division Sign-Off) Division of Anesthesiology, General Hospital, Infection Control, Dental Devices

510(k) Number: K032010

OR Over-The-Counter _ Prescription Use (Per 21 CFR 801.109)