Information Collection

Potential Tobacco Product Violations Reporting

IC 201526 under ICR 201203-0910-002 · OMB 0910-0716.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0716 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FDA Form 3779 Potential Tobacco Product Violations Reporting	Form
FDA Form 3779 Potential FDA 3779 Paper form.pdf	Form
CDC Report Violation 2_29_2012.pdf Potential Tobacco Product Violations Reporting Mobile App Screenshot	IC Document
Screen shot of Tobacco Potential Violation Form Web Form.pdf Potential Tobacco Product Violations Reporting Form Web Screenshot	IC Document

IC Title:

Potential Tobacco Product Violations Reporting

Agency IC Tracking Number:

Is this a Common Form? No

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
Form	FDA Form 3779	Potential	FDA 3779 Paper form.pdf		Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Immunization Management

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,000	1,000
Annual IC Time Burden (Hours)	250	250
Annual IC Cost Burden (Dollars)	5	5

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Potential Tobacco Product Violations Reporting Mobile App Screenshot	CDC Report Violation 2_29_2012.pdf	02/29/2012
Potential Tobacco Product Violations Reporting Form Web Screenshot	Screen shot of Tobacco Potential Violation Form Web Form.pdf	02/29/2012

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