Follow-UP Activities for Product-Related Injuries

Consumer Product Incident Report

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Consumer Product Incident Report

NOTE: If you have a drywall complaint, please use our special drywall report form and questionaire thank you.

By filling out the form below and then submitting it, you can report any injury or death involving
consumer products to us, or report an unsafe product to us. 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 1-800-638-2772 or by sending an e-mail to [email protected]
Please be advised that you may be contacted by one of CPSC’s field Investigators if we wish to
obtain additional information about your report. It is possible that CPSC might want to obtain the
product involved in the incident for further evaluation so please try to retain the product for at least 30
days after you file this report.
AGAIN, 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.
Your name:

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):

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

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Consumer Product Incident Report

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Product model, serial #, manufacture date/date code if available:

Was the product damaged, repaired or modified?

Yes

If yes, before or after the incident?

Before

No

After

Please describe damage / repair / modification:
When was the product purchased?
Do you still have the product?

Yes

No

Have you contacted the manufacturer?

Yes

No

If yes, please try to retain the product for at least 30 days after you file this report

If not, do you plan to contact them?

Yes

No

I request that you do not release my name
May we use your name
with this report?

You may release my name to the manufacturer but I request that you do not release it to the general public
You may release my name to the manufacturer and to the public

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

Consumer Safety (Home) | About CPSC | Library | Business

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

2/4/2010