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Consumer Product Safety Report Form

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
Address
City
State
Zip
Phone
Email


In the space below, describe the incident or hazard, including a description of injuries, and provide answers to the following questions:

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?

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