Follow-UP Activities for Product-Related Injuries

State Attorney General and Health Department, Fire, Police, and Insurance Investig... Page 1 of 2

State Attorney General and Health Department, Fire, Police, and Insurance Investigator
Consumer Product Incident Report

This form is for use by state Attorney General and Health Department offices, or fire, police, and
insurance investigators to report injuries or deaths involving consumer products, or unsafe
products, to CPSC. We may contact you by mail, phone or Internet email for further details. In
addition, you will be contacted to confirm the information you sent. Please provide as much
information as possible. Your name, address, and telephone number are optional, but we can't
contact you without that information. You can also report an incident or unsafe product by calling tollfree at 1-800-638-8095 or by sending an e-mail to [email protected]
CPSC does not have jurisdiction over automobiles, trucks and motorcycles, car seats protecting
children in on-road vehicles, foods, medicines, cosmetics, and medical devices, or
dissatisfaction with business practices (links to the proper agencies can be found on the "Report
Unsafe Products" page).
When filling out the form, use the TAB key or your mouse to go to the next data area. Use the scroll
bar to scroll down the form. Please note that the "Source of Report" field must be changed from
"Please Select".

Source of Report: Please Select

Name of victim:

Name of Investigator:

Victim's address:

Department/Affiliation:

Victim's city:

Your address:

Victim's state:

City:
State:

The term ‘Victim’ covers any individual killed, injured
or exposed to a possible product-related hazard and
does not imply that the product caused an incident.

Please Select

Please Select

Victim's zip code:
Victim's telephone:

Zip code:

(at time of incident)

Victim's age:

Your email address:

Victim's sex:

Your telephone:

Female

Male

Please describe the incident or hazard, including description of injuries:

Is your office/department/agency conducting a concurrent investigation? Please provide current status to include the companies contacted,
product testing completed and summary of results, and any legal action taken or anticipated:

Date of Incident:
Describe product involved:
Product Brand Name/Manufacturer:

https://www.cpsc.gov/cgibin/fpinc.aspx

2/4/2010

State Attorney General and Health Department, Fire, Police, and Insurance Investig... Page 2 of 2

Manufacturer street address:
Place where manufactured (city and state or country):
Product model, serial #, & date of manufacture or date code if available:
When was the product purchased?
Is the product available for examination?

Yes

No

Don't Know

If yes, where is it located?

Send to CPSC

Clear Form

This information is collected by authority of 15 U.S.C. 2054 and will be entered into a
database by a Consumer Product Safety Commission contractor. The information is
not retrievable by name. The information may be shared with product manufacturers,
distributors, or retailers. However, no names or other personal information will be
disclosed without explicit permission.
OMB Control Number 3041-0029

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https://www.cpsc.gov/cgibin/fpinc.aspx

2/4/2010