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⚠️ Notice: This information collection may be referencing outdated material.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 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
PTVR Call Center General Instructions.doc Telephone Script IC Document

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	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 %

	Approved	Previously Approved
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

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
Telephone Script	PTVR Call Center General Instructions.doc	10/18/2013

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