If you or a family member have
experienced a recent aquatic injury involving a consumer product (e.g., diving board, pool
cover, floatation device, etc.), please provide the following information and press the SUBMIT button. We will forward this data to the Consumer Product Safety
Commission.
Name
Email Address
Address
City
State
Zip
Phone
Please provide answers to the following
questions in the space below:
Name of victim (if different from
above)
Victim's address
Victim's age at time of incident
Victim's sex
Date of Incident
Describe product involved
Product Brand Name/Manufacturer
Is product involved still available?
Product model and serial number
When was the product purchased?
