Product Safety Incident Form

About this form

Before completing this form

Please note that this form should only be used by people who live in New Zealand.

When to use this form

Use this form to report a concern regarding a potentially unsafe product. Please provide as much detail as possible, as this will assist the Ministry in its consideration of your complaint.

Response times

We will normally reply within 15 working days. Response times may be slower during holiday periods or other exceptional circumstances.

Contact details

Information marked with an asterisk* must be completed to enable you to submit this form.

Title:
Name:
Street address:
Suburb:
City / town:
Phone number:
Cell phone number:
E-mail address:*

Product details

Product brand name and model number:
Bar code (if shown):
Date of purchase:
Where was it purchased from:
Manufacturer or importer (if known):
Country of manufacture (if known):
What standards number or certification marks (eg, "S" mark) are shown (if any)?
Do you have a sample of the product available for us to review if required?	Yes No

Incident details

Date incident occurred:
Please describe the incident:

Injury details

Was there an injury?	Yes No
Describe the injury:
Was there a doctor's visit required?	Yes No
Was hospital admission required?	Yes No

Action details

Have you contacted the retailer?	Yes No
If yes, please provide the name, address and phone number of person and company contacted:
Date of contact:
Was the response:	Sympathetic Unsympathetic
Have you contacted the distributor?	Yes No
If yes, please provide the name, address and phone number of person and company contacted:
Date of contact:
Was the response:	Sympathetic Unsympathetic

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Important: please check that you have filled out all the fields before submitting.

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