Follow-UP Activities for Product-Related Injuries

Health Care Professional Consumer Product Incident Report

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Health Care Professional Consumer Product Incident Report

This form is for use by physicians and other health care professionals to report patient 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 toll-free 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.
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.
Health Care Provider:

Name of victim:

Your address:

Victim's address:

City:

Victim's city:

State:

Victim's state:

Please Select

Zip code:

Victim's zip code:

Your email address:

Victim's telephone:

Your telephone:

Victim's age:

Date of Incident:

Victim's sex:

Please Select

(at time of incident)
Female

Male

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

Describe product involved:
Product Brand Name/Manufacturer:
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

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

Clear Form

2/4/2010

Health Care Professional Consumer Product Incident Report

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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/hcpinc.aspx

2/4/2010