Form 0920-0338 Ingredient Reporting Format

Form Approved
OMB No. 0920-0338
Exp. xx/xx/20xx

Recommended Smokeless Tobacco Ingredient Reporting Format - CSTHEA
Please attach additional pages if necessary

Date
Office on Smoking and Health
Attn. FCLAA Program Manager
4770 Buford Hwy., NE, MS S107-7
Atlanta, GA 30341

This ingredient report is being submitted pursuant to the Comprehensive Smokeless Tobacco Health
Education Act (CSTHEA), 15 U.S.C. §4403(a).

Company Name(s)*

Brand(s)†

Product category(ies)† (check all that apply)
______Dry snuff
______Moist (wet) snuff
______Snuff portion pouch
______Snus
______Snus portion pouch
______Plug
______Twist
______Loose leaf
______Compressed (pellet, tablet)
______Other (specify)

*If this Ingredient Report is submitted by a designated individual or entity on behalf of a smokeless tobacco product
manufacturer, packager, or importer, the form must specify on whose behalf the submission is being made.
†Inclusion of the brand name and product type for ingredients is not required under CSTHEA.

Public reporting burden of this collection of information is estimated to average 6.5 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden to CDC Reports Clearance Officer,
1600 Clifton Road, MS-74, Atlanta, GA 30333, ATTN: PRA (0920-0338).

Form Approved
OMB No. 0920-0338
Exp. xx/xx/20xx
Ingredient Name¶

CAS Registry Number§

¶

Public reporting burden of this collection of information is estimated to average 6.5 hours per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any
other aspect of this collection of information, including suggestions for reducing this burden to CDC Reports Clearance Officer,
1600 Clifton Road, MS-74, Atlanta, GA 30333, ATTN: PRA (0920-0338).