All SEC15

INCIDENT INVESTIGATION ASSIGNMENT INSTRUCTIONS
FY2020 Compliance Assignment

DOCUMENT NUMBER:
DATE OF INCIDENT:

CATID:

FOLLOW-UP REQUESTED

HAZARD ANALYSIS

SECT 15

PRIMARY CONTACT:
ASSIGNMENT MESSAGE:
Please investigate the attached

fatal

non-fatal incident involving a

[general name of product]

This assignment is to be completed as
on-site investigation
telephone investigation
on-site investigation if sample available, otherwise telephone investigation
Priority level:

AA

BB

CC

Justification for AA or BB priority:
STATE in which incident occurred:
Incident and/or exemplar sample collection for Commission evaluation:
Yes, obtain entire incident product, if available
Yes, obtain part of incident product []
Obtain [] exemplar(s).
No sample collection necessary

Note: only one sample collection box above can by marked in the system – please see Instructions to Investigator section below for additional sample collection information, if applicable.

Instructions to Investigator:

(Note: if specialized instructions ARE included here but appear to be incomplete, contact the requestor for additional guidance.)

Obtain all official reports.
Verify incident scenario. Provide complete product identification including: manufacturer, brand, date
manufactured, place of purchase, date of purchase, model/serial numbers, cost, etc.
Please include primary and any backup contacts in the distribution of the completed IDI.
Please refer to any/all applicable guidelines and data record sheets.
If this assignment is requested by Compliance but is listed as a category in the Criteria and Rationales, then the report should also
meet the requirements of the Criteria and Rationales including use of any applicable guidelines and data record sheets. For
assignments requested by EP, if it is clear that a product defect is involved, then the report must also meet Compliance requirements.

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Area below will be completed in Data Systems _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Person(s) to Contact:
Task Number:
Assigned to:

CPSC FORM 324A

Date:
Processed by: lew