<table style="width:100%;">
<colgroup>
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 5%" />
<col style="width: 6%" />
<col style="width: 11%" />
<col style="width: 8%" />
<col style="width: 9%" />
<col style="width: 5%" />
<col style="width: 5%" />
<col style="width: 4%" />
<col style="width: 1%" />
<col style="width: 5%" />
<col style="width: 3%" />
<col style="width: 7%" />
<col style="width: 18%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="6" rowspan="5"><p><strong>REQUEST FOR MANUSCRIPT
CLEARANCE</strong></p>
<p><em>(Submit 3 copies of Manuscript with form)</em></p></td>
<td colspan="7">DATE OF REQUEST</td>
<td colspan="2"><h4 id="for-teb-use-only">FOR TEB USE ONLY</h4></td>
</tr>
<tr class="even">
<td colspan="7" rowspan="4">     </td>
<td colspan="2">MS NO.</td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="2">DATE RECEIVED</td>
</tr>
<tr class="odd">
<td colspan="2">     </td>
</tr>
<tr class="even">
<td colspan="7">1. PERSON TO CONTACT</td>
<td colspan="8">2. PHONE NUMBER / MAIL SYMBOL</td>
</tr>
<tr class="odd">
<td colspan="7">     </td>
<td colspan="8">     </td>
</tr>
<tr class="even">
<td colspan="15">3. TITLE OF MANUSCRIPT</td>
</tr>
<tr class="odd">
<td colspan="15">     </td>
</tr>
<tr class="even">
<td colspan="15">4. AUTHOR(S)</td>
</tr>
<tr class="odd">
<td colspan="15">     </td>
</tr>
<tr class="even">
<td colspan="7">5. CENTER(S) AND DIVISIONS</td>
<td colspan="8">6. CENTER PROGRAM</td>
</tr>
<tr class="odd">
<td colspan="7">     </td>
<td colspan="8">     </td>
</tr>
<tr class="even">
<td colspan="4">7. DISK AVAILABLE</td>
<td colspan="11">8. GIVE 2 OR 3 KEYWORDS DESCRIBING SUBJECT OF
PAPER</td>
</tr>
<tr class="odd">
<td colspan="4"> Yes No</td>
<td colspan="11">     </td>
</tr>
<tr class="even">
<td colspan="15">9. TO BE PUBLISHED AS <em>(Check one)</em></td>
</tr>
<tr class="odd">
<td rowspan="2">a.</td>
<td rowspan="2"></td>
<td colspan="3" rowspan="2">JOURNAL ARTICLE<br />
<em>(Give name of journal)</em></td>
<td colspan="10">NAME OF JOURNAL</td>
</tr>
<tr class="even">
<td colspan="10">     </td>
</tr>
<tr class="odd">
<td rowspan="2">b.</td>
<td rowspan="2"></td>
<td colspan="3" rowspan="2">BOOK CHAPTER<br />
<em>(Give of book)</em></td>
<td colspan="10">TITLE OF BOOK</td>
</tr>
<tr class="even">
<td colspan="10">     </td>
</tr>
<tr class="odd">
<td rowspan="3">c.</td>
<td rowspan="3"></td>
<td colspan="3" rowspan="3">ABSTRACT FOR MEETING</td>
<td colspan="10">IF YOU CHECKED ITEM C, D, E, OR F, COMPLETE THE
INFORMATION BELOW:</td>
</tr>
<tr class="even">
<td colspan="5">MEETING SPONSOR</td>
<td colspan="4">DATE</td>
<td>PLACE</td>
</tr>
<tr class="odd">
<td colspan="5">     </td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="even">
<td>d.</td>
<td></td>
<td colspan="3">SYMPOSIUM</td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td>e.</td>
<td></td>
<td colspan="3">PROCEDURES</td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="even">
<td>f.</td>
<td></td>
<td colspan="3"><p>SPEECH ONLY</p>
<p><em>(No publication)</em></p></td>
<td colspan="5">     </td>
<td colspan="4">     </td>
<td>     </td>
</tr>
<tr class="odd">
<td>g.</td>
<td></td>
<td colspan="3">OTHER <em>(Specify)</em></td>
<td colspan="10">     </td>
</tr>
<tr class="even">
<td rowspan="2">h.</td>
<td colspan="13" rowspan="2">IF CLEARANCE IS REQUESTED TO MEET DEADLINE,
GIVE DATE</td>
<td>DATE</td>
</tr>
<tr class="odd">
<td>     </td>
</tr>
<tr class="even">
<td colspan="6">10. TITLE</td>
<td colspan="8">SIGNATURE</td>
<td>DATE</td>
</tr>
<tr class="odd">
<td colspan="6"><p>a. BRANCH CHIEF</p>
<p>     </p></td>
<td colspan="8"></td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="6"><p>b. DIRECTOR, DIVISION OF</p>
<p>     </p></td>
<td colspan="8"></td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="6"><p>c. ASSOCIATE DIRECTOR FOR</p>
<p>     </p></td>
<td colspan="8"></td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="6"><p>d. OTHER AUTHORIZED SIGNATURES</p>
<p>     </p></td>
<td colspan="8"></td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="6"><p>e. CHIEF, TECHNICAL EDITING BRANCH</p>
<p>     </p></td>
<td colspan="8"></td>
<td>     </td>
</tr>
<tr class="even">
<td colspan="6"><p>f. CENTER DIRECTOR <em>(or designee)</em></p>
<p>     </p></td>
<td colspan="8"></td>
<td>     </td>
</tr>
<tr class="odd">
<td colspan="12">11. <strong>FOR HFF USE ONLY</strong></td>
<td colspan="3">12. REMARKS</td>
</tr>
<tr class="even">
<td colspan="9">GLP / QA STATUS</td>
<td colspan="2">YES</td>
<td>NO</td>
<td colspan="3" rowspan="5">     </td>
</tr>
<tr class="odd">
<td colspan="9">a. Was study conducted under GLP Regulation?</td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="9"><ol start="2" type="a">
<li><p>(1) If yes, was final report submitted to and approved by CFSAN
Quality Assurance Unit?</p></li>
</ol></td>
<td colspan="2" rowspan="3"></td>
<td rowspan="3"></td>
</tr>
<tr class="odd">
<td colspan="3">(2) BFQ Number</td>
<td colspan="5">     </td>
<td></td>
</tr>
<tr class="even">
<td colspan="3"></td>
<td colspan="5"></td>
<td></td>
</tr>
</tbody>
</table>