Follow-UP Activities for Product-Related Injuries

MECAP Report Form

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Medical Examiner and Coroner Reporting Form

This is an on-line form which allows Medical Examiners and Coroners to file a MECAP report. If you
desire an alternative reporting method, you can report a case by telephone by calling (toll free) (800)
638-8095. Say “This is a MECAP report.” You will then be placed in contact with the MECAP Project
Manager for your state, who will ask for the information noted below. You can also send a report by
email to [email protected], or fax it to (800) 809-0924.
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.
Your Name:

Medical Examiner’s/
Coroner’s Case No:

Office:

Medical Examiner’s/
Coroner’s Name:

City:

Date of accident:

State:

Date of death:

County:

Accident location - city:
Accident location - state:

Please Select

Telephone:
Please Select

Email address:

Brief description of accident sequence [please include the age and sex of the victim(s)]:

Name, address and telephone number of any state/local personnel who investigated the accident:

Type of consumer product involved:
Manufacturer and brand name of product:
Product model and serial numbers:
Cause of death:
Is product available for examination?

Yes

No

If yes, where?

Submit

Clear Form

OMB Control Number 3041-0029

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

2/4/2010