Consumer Product Incident Report

Consumer Product Incident Report

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 info@cpsc.gov
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.

Your name:
Your address:
City:
State:
Zip code:
Your email address:
Your telephone:
Date of Incident:

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.
Name of victim:
Victim's address:
Victim's city:
Victim's state:
Victim's zip code:
Victim's telephone:
Victim's age:	(at time of incident)
Victim's sex:	Female Male

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

Describe product involved:
Product Brand Name/Manufacturer:
Place where manufactured (city and state or country):
Product model, serial #, & date of manufacture or date code if available:
When was the product purchased?
Do you still have the product?	Yes No

May we use your name
with this report?

I request that you do not release my name
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

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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