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⚠️ Notice: This information collection may be referencing outdated material.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 FDA-3779 5-2016 version.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	FDA-3779 5-2016 version.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: 400	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	800	800
Annual IC Time Burden (Hours)	200	200
Annual IC Cost Burden (Dollars)	4	4

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.