Potential Tobacco Product Violations Reporting

Potential Tobacco Product Violations Reporting Form

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Form FDA 3779 Potential Tobacco Product Violations Reporting Form and Instruction
FDA 3779 Potential Tobacco Product Violations Report Form FDA 3779.pdf Form and Instruction

Information Collection (IC) Details

IC Title:	Potential Tobacco Product Violations Reporting	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	FDA 3779	Potential Tobacco Product Violations Report	Form FDA 3779.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2,685	Number of Respondents for Small Entity: 200

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 99 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	5,370	3,870	1,500
Annual IC Time Burden (Hours)	1,343	968	375
Annual IC Cost Burden (Dollars)	24	17	7

Documents for IC

Title	Document	Date Uploaded
No associated records found

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