0920-0338 Nicotine Report Format

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

Recommended Format for Smokeless Tobacco Nicotine Data Reporting - 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 nicotine report is being submitted pursuant to the Comprehensive Smokeless Tobacco Health Education Act (CSTHEA), 15 U.S.C.
§4403(a).
Manufacturer* (Please indicate if the product is manufactured for another company)

Variety (Including brand families and brand variations)

Brand Name (e.g., Skoal Bandits, Skoal Long Cut Cherry, Skoal Long Cut Wintergreen, etc.)

*If this Ingredient Report is submitted by a designated individual or entity on behalf of a cigarette manufacturer, packager, or importer, the form must specify on
whose behalf the submission is being made.
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

Product category (check one)
______Dry snuff
______Moist (wet) snuff
______Snuff portion pouch
______Snus
______Snus portion pouch
______Plug
______Twist
______Loose leaf
______Compressed (pellet, tablet)
______Other (specify)
Documentation of method used for random sample section

Documentation of Standards Addition Assay, including nicotine concentrations selected for standard curve

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

Smokeless Tobacco Analytical Data

Sample
Date

Manufacture
Date

Lot
Number

Sample
Fraction1

Age of the
product in days
when received
by testing
facility/storage
conditions prior
to analysis

Nicotine2

Total
Moisture3

pH

Estimated
unionized
(free)
nicotine2

Estimated
unionized
(free)
nicotine3

1
2
3
4
Final mean value
with 95%
confidence
interval
Range of values
Estimated
precision of the
mean4

1

Number of randomly sampled, sealed, packaged (so as to be representative of the product that is sold to the public) smokeless tobacco
products selected per sampling date; 2Units for nicotine and estimated unionized (free) nicotine content are milligrams of nicotine (or unionized
(free) nicotine) per gram of tobacco (mg/g); 3Total moisture and estimated unionized (free) nicotine as a percentage (%); 4Reported as the
standard deviation.

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).