Information Collection

Assessment Questionnaire

IC 278148 under ICR 202511-0910-004 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
SmallDispensersAssessment_AttachmentC_Questionnaire_11.2025.docx	Other-Questionnaire
SmallDispensersAssessment_AttachmentA_Invitation_11.2025.docx Invitation email	IC Document

IC Title:

Agency IC Tracking Number:

CDER

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
Other-Questionnaire					Yes	Yes	Fillable Fileable Signable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 922

Number of Respondents for Small Entity: 922

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to New Statute
Annual Number of Responses for this IC	922	922
Annual IC Time Burden (Hours)	2,305	2,305
Annual IC Cost Burden (Dollars)	150,415	150,415

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Invitation email		11/20/2025

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

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