Form FDA Form 3779 FDA Form 3779 Potential

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration

FDA FORM 3779
POTENTIAL TOBACCO PRODUCT VIOLATIONS REPORTING

Form Approved: OMB No. 0910-xxxx
Expiration Date: xx/xx/xxxx
(See page 3 for Burden Statement)

Use this form to report potential tobacco related violations of the Federal Food, Drug, and Cosmetic Act and associated
regulations. These submissions are reviewed by FDA's Center for Tobacco Products, Office of Compliance and
Enforcement.
WHO can report? - Any member of the public.

Tell us:
WHEN did you see the potential violation?
WHERE did the potential violation occur?
WHAT is the potential violation?
WHY report? - Information we receive from the public is often very helpful in identifying problems with marketed products
and possible violations of the laws that we enforce.
To submit your report, use the form below:

Date and State Where Violation Occurred
Date potential violation
occurred

I do not recall the date this
potential violation occurred

State in which potential violation occurred

Description of Product
Tobacco brand

Type

Potential violation type
(choose all that apply)

Type of potentially
violative promotional
materials
(choose all that apply)

Sales to Minors
Flavored cigarette sales

Vending machine/self-service display/direct
access to cigarette or smokeless tobacco

Advertising/promotion/marketing

Sale of cigarettes in packs of less than 20

Free samples

Unsure

Newspaper

Price signage

Magazine

Posters

Periodicals

Coupons

Billboard

Internet advertising

Direct Mail

Unsure

In-store advertisements
(Continued on next page)

FORM FDA 3779 (2012)

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration

FDA FORM 3779
POTENTIAL TOBACCO PRODUCT VIOLATIONS REPORTING
Who potentially
violated?
(choose all that apply)

Retailer

Distributor

Manufacturer

Unsure

Form Approved: OMB No. 0910-xxxx
Expiration Date: xx/xx/xxxx
(See page 3 for Burden Statement)

Importer

Description of
potential violation
(character limit 1000)

Please provide name and physical address of the potentially violative party/location below by potential violator types, if known

Brand, retailer,
manufacturer, importer, or
distributor name
(character limit 250)
Street Address
Street Address 2
City

State/Province/Region

Postal/ Zip Code
If report is about a Web site,
please provide Web site
address here:
All reports will remain confidential to the extent allowed by law. For more information about FDA's internet policies
please visit: http://www.fda.gov.AboutFDA/AboutThisWebsite/WebsitePolicies/default.htm

May we contact you if we
need additional
Information?

Yes, CTP may contact me. (Please fill in contact information below.)
No, I want my report to be anonymous

Name (character limit 250)
Affiliation (such as
company, school, or
group) (character limit 250)
Street Address
Address Line 2
City

State/Province/Region

Postal/ Zip Code

Phone number

(Continued on next page)

FORM FDA 3779 (2012

Page 2

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Food and Drug Administration

FDA FORM 3779
POTENTIAL TOBACCO PRODUCT VIOLATIONS REPORTING

Form Approved: OMS No. 0910-xxxx
Expiration Date: xx/xx/xxxx
for Burden Statement)
(See below

E-mail
I would like to receive an
e-mail to notify me that CTP
got my complaint

Yes
No

In order to receive a response, please configure your e-mail spam/junk filter to allow messages from
[email protected]. In most cases, this is solved by adding our e-mail address to your address book
If you would rather submit your report to us in writing along with any attachments, please do so at the following address:
Tobacco Product Violation Report, Office of Compliance and Enforcement
FDA Center for Tobacco Products
c/o Document Control Center
9200 Corporate Boulevard
Rockville, MD 20850-3229
To reach us by telephone, please call 1-877-CTP-1373, and select option 3. You may also e-mail us at
[email protected].

Submit by E-mail

Print Form

Reset Form

OMB Paperwork Reduction Act Statement
Public reporting burden for this collection of information is estimated to average 0.25 hours (15 minutes) per
response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining
the data needed, and completing and reviewing the collection of information. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:

Department of Health and Human Services
Food and Drug Administration
Office of the Chief Information Officer
1350 Piccard Drive, 420A
Rockville, MD 20850
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number.

FORM FDA 3779 (2012)

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