CONSUMER PRODUCT SAFETY COMMISSION (CPSC) COMPLAINT

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INCIDENT REPORT TO CPSC

This form is designed to help organize information for submission to the Consumer Product Safety Commission. The official report should be filed at SaferProducts.gov or by calling 1-800-638-2772.

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SECTION 1: REPORTER INFORMATION

Reporter Type:
☐ Injured party
☐ Parent/Guardian of injured party
☐ Attorney representing injured party
☐ Witness to incident
☐ Other: [________________________________]

Contact Information:

Field	Information
Full Name	[________________________________]
Address	[________________________________]
City, State, ZIP	[________________________________]
Phone Number	[________________________________]
Email Address	[________________________________]
Preferred Contact Method	☐ Phone ☐ Email ☐ Mail

Confidentiality Preference:
☐ My personal information may be shared with the manufacturer
☐ My personal information should remain confidential
☐ My report may be published on SaferProducts.gov
☐ My report should NOT be published on SaferProducts.gov

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SECTION 2: PRODUCT INFORMATION

Product Details:

Field	Information
Product Name	[________________________________]
Product Description	[________________________________]
Manufacturer Name	[________________________________]
Brand Name	[________________________________]
Model Number	[________________________________]
Serial Number	[________________________________]
UPC/Barcode	[________________________________]
Date Code/Lot Number	[________________________________]

Product Purchase Information:

Field	Information
Where Purchased	[________________________________]
Date of Purchase	[__/__/____]
Purchase Price	$[________________________________]
Receipt Available	☐ Yes ☐ No
Online or In-Store	☐ Online ☐ In-Store

Product Category (select one):
☐ Appliances - Kitchen
☐ Appliances - Other
☐ Children's Products - Toys
☐ Children's Products - Nursery/Baby
☐ Clothing/Accessories
☐ Electronics/Computers
☐ Exercise/Sports Equipment
☐ Furniture
☐ Home Improvement/Tools
☐ Household Products
☐ Outdoor/Recreational
☐ Personal Care Products
☐ Other: [________________________________]

Product Condition:
☐ New when purchased
☐ Used when purchased
☐ Secondhand/Gifted
☐ Unknown

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SECTION 3: INCIDENT DESCRIPTION

Date of Incident: [__/__/____]

Time of Incident: [____:____] ☐ AM ☐ PM

Location of Incident:
[________________________________]
[________________________________]
City: [________________________________]
State: [________________________________]
ZIP: [________________________________]

Location Type:
☐ Private residence
☐ School/Daycare
☐ Business/Store
☐ Outdoor/Park
☐ Other: [________________________________]

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Detailed Description of Incident

Please describe exactly what happened, including what the product was being used for, who was using it, and how the incident occurred:

[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]

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Product Failure/Defect Description

Type of Defect:
☐ Product broke/fell apart
☐ Product caught fire
☐ Product overheated
☐ Electrical shock/malfunction
☐ Sharp edges/points
☐ Choking hazard (small parts)
☐ Chemical/toxic exposure
☐ Tip-over hazard
☐ Entrapment/Strangulation hazard
☐ Missing/Inadequate warnings
☐ Assembly/Installation issue
☐ Other: [________________________________]

Describe the specific defect or failure:
[________________________________]
[________________________________]
[________________________________]
[________________________________]

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SECTION 4: INJURY/HARM INFORMATION

Was there an injury?
☐ Yes
☐ No (near-miss or potential hazard only)

If yes, who was injured?
☐ Reporter (myself)
☐ Child (under 18)
☐ Other adult
☐ Multiple people

Victim Information:

Field	Information
Name	[________________________________]
Age at time of incident	[____] years
Gender	☐ Male ☐ Female ☐ Other
Relationship to reporter	[________________________________]

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Injury Details

Type of Injury (check all that apply):
☐ Laceration/Cut
☐ Bruise/Contusion
☐ Burn (thermal)
☐ Burn (chemical)
☐ Electrical injury
☐ Fracture/Broken bone
☐ Sprain/Strain
☐ Head injury/Concussion
☐ Eye injury
☐ Choking
☐ Poisoning/Chemical exposure
☐ Allergic reaction
☐ Internal injury
☐ Amputation
☐ Death
☐ Other: [________________________________]

Body Part(s) Affected:
☐ Head/Face
☐ Neck
☐ Shoulder/Arm
☐ Hand/Fingers
☐ Chest/Torso
☐ Back
☐ Hip/Leg
☐ Foot/Toes
☐ Internal organs
☐ Other: [________________________________]

Severity of Injury:
☐ Minor (no medical treatment needed)
☐ Moderate (outpatient medical treatment)
☐ Serious (emergency room visit)
☐ Severe (hospitalization required)
☐ Permanent injury/disability
☐ Fatal

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Medical Treatment

Was medical treatment received?
☐ Yes
☐ No

If yes, provide details:

Field	Information
Type of treatment	☐ First aid ☐ Doctor visit ☐ Urgent care ☐ Emergency room ☐ Hospital admission
Hospital/Facility name	[________________________________]
Date(s) of treatment	[__/__/____]
Treating physician	[________________________________]
Days hospitalized	[____] days
Ongoing treatment needed	☐ Yes ☐ No

Description of medical treatment:
[________________________________]
[________________________________]
[________________________________]

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SECTION 5: PROPERTY DAMAGE

Was there property damage?
☐ Yes
☐ No

If yes, describe the damage:
[________________________________]
[________________________________]
[________________________________]

Estimated value of damage: $[________________________________]

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SECTION 6: EVIDENCE AND DOCUMENTATION

Product Availability:
☐ I still have the product
☐ The product was destroyed in the incident
☐ I returned the product
☐ I disposed of the product
☐ Other: [________________________________]

If you have the product, where is it stored?
[________________________________]

Do you have the following documentation?
☐ Photographs of the product
☐ Photographs of the defect
☐ Photographs of injuries
☐ Photographs of property damage
☐ Purchase receipt
☐ Product packaging
☐ Product instructions/manual
☐ Warranty information
☐ Medical records
☐ Police report
☐ Fire department report
☐ Video of incident
☐ Other: [________________________________]

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SECTION 7: PRIOR KNOWLEDGE AND SIMILAR INCIDENTS

Were you aware of any warnings or recalls for this product before the incident?
☐ Yes
☐ No

If yes, please explain:
[________________________________]
[________________________________]

Do you know of other similar incidents involving this product?
☐ Yes
☐ No

If yes, please provide details:
[________________________________]
[________________________________]

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SECTION 8: MANUFACTURER CONTACT

Have you contacted the manufacturer about this incident?
☐ Yes
☐ No

If yes:

Field	Information
Date contacted	[__/__/____]
Method of contact	☐ Phone ☐ Email ☐ Letter ☐ Website
Person/Department contacted	[________________________________]
Reference/Case number	[________________________________]

What was the manufacturer's response?
[________________________________]
[________________________________]
[________________________________]

Did the manufacturer offer any remedy?
☐ Refund offered: $[________________________________]
☐ Replacement offered
☐ Repair offered
☐ No remedy offered
☐ Response pending
☐ Other: [________________________________]

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SECTION 9: ADDITIONAL INFORMATION

Is there anything else CPSC should know about this incident?
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]

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SECTION 10: DECLARATION AND SIGNATURE

I declare that the information provided in this report is true and accurate to the best of my knowledge. I understand that knowingly submitting false information may be subject to penalties.

☐ I consent to CPSC contacting me for additional information.
☐ I consent to CPSC sharing my report with the manufacturer for response.
☐ I understand that my report may be published on SaferProducts.gov (with personal information removed).

Signature: ________________________________________

Printed Name: [________________________________]

Date: [__/__/____]

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HOW TO FILE YOUR CPSC COMPLAINT

Online (Preferred Method)

Website: https://www.saferproducts.gov/
- Available 24/7
- Allows photo/document uploads
- Fastest processing

By Phone

CPSC Hotline: 1-800-638-2772
- Monday-Friday, 8:00 AM - 5:30 PM ET
- TTY: 301-595-7054

By Mail

Address:
U.S. Consumer Product Safety Commission
Attn: Reports
4330 East West Highway
Bethesda, MD 20814

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WHAT HAPPENS AFTER YOU FILE

1. Receipt: CPSC will confirm receipt of your report
2. Review: Staff investigators and product safety experts review reports
3. Manufacturer Notice: If you consent, CPSC notifies the manufacturer who has 10 business days to respond
4. Investigation: CPSC may investigate further based on reports
5. Action: Your report could contribute to:
   - Product recalls
   - Safety standards development
   - Penalty actions against manufacturers
   - Public warnings

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IMPORTANT NOTES

Preserve Evidence:
- Do NOT throw away the product
- Do NOT repair or alter the product
- Store it safely away from use
- Take photographs before storing
- Keep all packaging and documentation

Statute of Limitations:
Filing a CPSC complaint does NOT extend the statute of limitations for legal claims. Consult an attorney promptly if you intend to pursue legal action.

Privacy:
- Your personal information is protected
- Reports published on SaferProducts.gov do not include your contact information
- You can choose whether to allow manufacturer contact

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FILING CHECKLIST

☐ Completed all sections of this form
☐ Gathered product identifying information
☐ Photographed the product and defect
☐ Photographed any injuries
☐ Located purchase receipt (if available)
☐ Preserved the product in a safe location
☐ Obtained copies of medical records
☐ Decided on privacy preferences
☐ Ready to submit at SaferProducts.gov

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SOURCES AND REFERENCES

• Consumer Product Safety Commission
• SaferProducts.gov - File a Report
• CPSC Recall Information
• USAGov - Consumer Product Safety Commission