Tobacco Health Document Submission

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0910-0654 can be found here:

Documents and Forms

Document Name Document Type
904a4 Health Documents_v4.pdf Other-screenshots
904(a)(4) draft guidance 12 22 2009.pdf 904(a)(4) draft guidance 12 22 2009 IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Tobacco Health Document Submission	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-screenshots			904a4 Health Documents_v4.pdf		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: 200	Number of Respondents for Small Entity: 1

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 20 %

	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	800	760	40
Annual IC Time Burden (Hours)	8,000	7,600	400
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
904(a)(4) draft guidance 12 22 2009	904(a)(4) draft guidance 12 22 2009.pdf	12/23/2009

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