VINYL EXAMINATION GLOVES, POWDER FREE, GREEN COLOR

K041745 · Arista Latindo Industrial Ltd. P.T · LYZ · Jul 15, 2004 · General Hospital

Device Facts

• Record ID: K041745
• Device Name: VINYL EXAMINATION GLOVES, POWDER FREE, GREEN COLOR
• Applicant: Arista Latindo Industrial Ltd. P.T
• Product Code: LYZ · General Hospital
• Decision Date: Jul 15, 2004
• Decision: SESE
• Submission Type: Traditional
• Regulation: 21 CFR 880.6250
• Device Class: Class 1

Indications for Use

A patient examination glove is a disposable device intended for medical purpose that is worn on the examiner's hand or finger to prevent contamination between patient and examiner.

Device Story

Vinyl examination gloves; disposable; worn on examiner's hand or finger; intended to prevent cross-contamination between patient and examiner during medical procedures; used in clinical settings; non-sterile; powder-free; green color.

Clinical Evidence

No clinical data; bench testing only.

Technological Characteristics

Vinyl material; powder-free; green color; disposable; non-sterile; form factor is a hand-worn glove.

Indications for Use

Indicated for use as a disposable medical device 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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Food and Drug Administration 9200 Corporate Boulevard Rockville MD 20850

JUL 1 5 2004

Ms. Linga Sumarta Quality Assurance Manager Arista Latindo Industrial Limited PT 128 Jalan Kyai Haji Muhammad Mansyur Jakarta Basrat, INDONESIA 11210

Re: K041745

Trade/Device Name: Vinyl Examination Gloves, Powder Free, Green Color Regulation Number: 21 CFR 880.6250 Regulation Name: Patient Examination Gloves Regulatory Class: I Product Code: LYZ Dated: June 21, 2004 Received: June 28, 2004

Dear Ms. Sumarta:

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 - Ms. Sumarta

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 yours,

Susan Russon
C. Chiu Lin. Ph.D.

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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## INDO INDUSTRIA

OFFICE : JL. K.H. MOH. MANSYUR 128 JAKARTA 11210 - INDONESIA. MAILING ADDRESS : P.O. BOX 4129 JKT 11041 - INDONESIA TELEPHONE : [phone] FAX : [phone]. E-MAIL : [e-mail]

## Section No. 3. ATTACHMENT #2

## INDICATIONS FOR USE STATEMENT

| Applicant: | PT. ARISTA LATINDO IND. LTD. |
|---------------------------|----------------------------------------------------|
| 510(k) Number (if known): | K041745 * |
| Device Name: | Vinyl Examination Gloves, Powder Free, Green Color |
| Indications For Use: | |

A patient examination glove is a disposable device intended for medical purpose that is worn on the examiner's hand or finger to prevent contamination between patient and examiner.

Prescription Use (Part 21 CFR 801 Subpart D)

AND/OR

Over-The-Counter Use (21 CFR 807 Subpart C)

(PLEASE DO NOT WRITE BELOW THIS LINE-CONTINUE ON ANOTHER PAGE IF NEEDED)

Concurrence of CDRH, Office of Device Evaluation (ODE)

Kai Muluy

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

510(k) Number.