Follow-UP Activities for Product-Related Injuries

Consumer Drywall Complaint Report

Page 1 of 3

Consumer Drywall Complaint Report

By filling out the form below and then submitting it, you can report a complaint involving drywall 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, telephone number and email address are optional, but we can't contact you without
that information. You can also report a drywall complaint 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.
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 limit entries in the larger, multiline boxes to 255 characters.

Your name:
Your address:
City:
State:

Please Select

Zip code:
Your email address:
Your telephone:
1. What are the ages and gender of the persons living in the home?

2. When did you move into your home? Date:
3. What year was your home built? Date:
4. Describe the style of your home (ranch, duplex, condominium, colonial, etc.)

5. What is the name and address of your builder and/or contractor?

6. If renovation of existing structure, provide dates:

7. Did the renovation include drywall?

Yes

No

8. Describe the work done in the renovation project.

9. If known, provide the name and address of the person that provided the drywall for the project.

10. Are you currently living at the address above?

Yes

No

OMB Control Number 3041-0029

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

2/4/2010

Consumer Drywall Complaint Report

11. Does your home use natural or LP gas service?

Page 2 of 3

Yes

No

Yes

No

11a. If yes, which type and for which appliances?

12. Have you noticed unusual odors in your home?

12a. If yes, describe the odors, and when you notice them.

13. How many air conditioner service calls have you had in the last 3 years?
13a. If any, describe the type of service needed and how often.

14. Have you observed any blackening or corrosion of copper or metal items in your home?

Yes

No

14a. If so, describe which items.

15. Describe any problems with the operations of your smoke, carbon monoxide detectors and security alarm systems in the last 3 years.

16. Has it been confirmed that Chinese manufactured drywall is present in your home?

Yes

No

16a. If so, by whom.

17. Do you know the name of the manufacturer of the imported drywall in your home?

Yes

No

17a. If so, provide the name(s) and how you learned this information..

18. Has anyone in the house experienced any health symptoms since the
installation of the imported drywall or since moving into the home?

Yes

No

18a. If so, describe the health symptoms and the age of the person.

19. Do you keep a record of your symptoms?

Yes

No

20. How often do the symptoms occur?

21. Did you (or household member) seek medical care or treatment for these symptoms?

Yes

No

21a. If so, describe (who sought care, date(s), the symptom present, type of care or treatment)

22. Have you and/or any member of your household experienced similar symptoms in the past?

Yes

No

22a. If so, when and under what circumstances.

23. Have you noticed any unusual patterns of operations of your light fixtures, light switches, circuit breaker box, wall
switches and receptacles, or any unusual sounds or smells coming from electrical components in the home?

Yes

No

OMB Control Number 3041-0029

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

2/4/2010

Consumer Drywall Complaint Report

Page 3 of 3

23a. If so, identify the item, age, date and describe the unusual pattern(s).

24. Have you had any unusual problems with appliances or with any electrical equipment
in the residence? In particular, have any appliances unexpectedly stopped working?

Yes

No

24a. If so, describe the type and age of appliance, nature of the problem and the dates of the occurrence.

25. Are you interested in being considered for participation in potential future studies of the imported drywall issue?

26. Have you contacted your builder or contractor about your drywall issues?

Yes

Yes

No

No

26a. If so, what was the response?

27. Have you filed a lawsuit for this matter?

Yes

No

27a. If so, provide the name, address and phone number of the attorney.

28. Do you know of anyone else in your community with complaints about drywall?

Yes

No

28a. If so, provide the name, address and phone number, if known.

29. Additional Comments.

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

OMB Control Number 3041-0029

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

2/4/2010