Information Collection

FDA's Center for Tobacco Products State Department of Health Electronic Cigarette Adverse Event Survey

IC 201322 under ICR 201012-0910-003 · OMB 0910-0500.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0500 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
State Health Officer final 3pm.doc	Other-Survey letter
FDA Rapid Response Survey Template CTP Adverse Events for Ecigs.doc OMB Justification Memo	IC Document

IC Title:

FDA's Center for Tobacco Products State Department of Health Electronic Cigarette Adverse Event Survey

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Survey letter			State Health Officer final 3pm.doc		No		Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 50

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50	50
Annual IC Time Burden (Hours)	800	800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
OMB Justification Memo	FDA Rapid Response Survey Template CTP Adverse Events for Ecigs.doc	02/27/2012

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.