Consumer Product Incident Report: Form for Consumers

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IMPORTANT NOTE: On the form link, right click and select "Save As" and save it on your local computer. Open the form using Adobe Acrobat Reader V9.0 or higher. Please do not edit the form within your browser, e.g. Internet Explorer.

• Office use only:
  • Date Received
  • Form Identifier CPS-SPC-0001.03

1 Information about this report

Protected when completed and received by Health Canada
Treasury Board Secretariat Government Security Policy

• Case Number
• Submission Number
• Report Type:
  • New
  • Update
• Product type:
  • Asbestos
  • Booster Seat
  • Candle
  • Carpet
  • Carriage Stroller
  • Cellulose Insulation
  • Charcoal
  • Chemical Product
  • Child Restraint System
  • Children's Sleepwear
  • Children's Jewelry
  • Cosmetic
  • Crib, Cradle, Bassinet
  • Electrical
  • Expansion Gate
  • Face Protector
  • Glass Door or Enclosure
  • Glazed Ceramics or Glassware
  • Hockey Helmet
  • Infant Feeding Bottle Nipples
  • Kettles
  • Lead (Contact with Mouth)
  • Lighter
  • Matches
  • Mattress
  • Pacifier
  • Playpen
  • Science Education Set
  • Smoke / Fire Alarm / Detector
  • Soda Bottle
  • Surface Coating
  • Tent
  • Textile
  • Toy
  • Vinyl Toy
  • Window Covering
  • Other - Not On This List

2 Information about who is reporting

• Relationship to injured / involved person:
  • Self
  • My child
  • My parent
  • My Spouse
  • Other Relative
  • My friend / neighbour / co-worker
  • Professional relationship (client, student, patient)
  • No relationship
• Name:
• Email:
• Telephone:
• Fax:
• Address:
• City:
• Province / Region:
• Country: Canada (default)
• Postal Code:

3 Information about the incident

If more than one person was affected, please report on the worst case.

• Date of the incident:
• Number of people affected:
• Sex:
  • Female
  • Male
• Age (years)
• Incident Type: Pick worst case
  • Death
  • Serious Injury
  • Injury
  • Product Defect
  • Incorrect/Insufficient Information
  • Recall
  • Property Damage
  • Incident, No Injury
  • Other
• Injury Type: Pick worst case:
  • No Injury
  • Amputation/Bleeding
  • Break, Fracture
  • Bruising, Scratches
  • Burn
  • Concussion
  • Cut
  • Dental Injury
  • Skin or Eye Irritation/Rash
  • Dislocation
  • Drowning
  • Electric Shock
  • Foreign Object Stuck in or on the body
  • Internal Organ Injury
  • Lack of Oxygen
  • Nerve Damage
  • Object Inhaled
  • Object Swallowed
  • Poisoning
  • Puncture
  • Sever Bruising
  • Skin Tear, Nail Detachment
  • Strain/Sprain
  • Other/Not Stated
• Body Part:
  • 25-50% of body
  • All parts of the body
  • Ankle
  • Arm
  • Ear
  • Elbow
  • Eyeball
  • Face (including eyelid, eye area and nose)
  • Finger
  • Foot
  • Hand
  • Internal (use with aspiration and ingestion)
  • Knee
  • Leg
  • Mouth
  • Neck
  • Not Recorded
  • Pubic Region
  • Shoulder (including clavicle, collarbone)
  • Toe
  • Trunk
  • Wrist
• Treatment:
  • None
  • First Aid
  • Provincial Health Care Info Service
  • Poison Control Centre
  • Family Doctor
  • Hospital-Emergency Room
  • Hospital-Other
  • Other Medical Professional
  • Other
  • Unknown
• Describe the incident, defect or problem:

4 Information about the product

• Product Brand and Name:
• Please include any of the information below that you can find on the product or packaging:
  • Model Number:
  • Serial Numbers:
  • Date Codes:
  • Universal Product Code / UPC / Bar Code: Enter all numbers
  • Certification / Standards: (e.g. CSA, ULC stickers)
  • Batch Number
• Product Description: (for example: colour, packaging, warnings on the label)

5 Information from the product label or package

• Business Name (Full legal name - No abbreviations):
• Address:
• City:
• Province / Region:
• Country:
• Postal Code:
• Website:
• Email:
• Telephone:
• Fax:

6 Information about where you got the product

• When did you get the product? (May be approximate)
• From whom did you get the product?
  • Purchased New
  • Purchased Used From Retailer
  • Purchased Used From Person (e.g. yard Sale)
  • Promotional Item
  • Gift
  • Other
• Business Name (Full legal name - No abbreviations):
• Address:
• City:
• Province / Region:
• Country:
• Postal Code:
• Website:
• Email:
• Telephone:
• Fax:

7 Documents and Pictures

• Browse
• File Name
• Document Type
  • Advertisement
  • Correspondence
  • Distribution Records (S13)
  • Image - Incident
  • Image - Location
  • Image - Product
  • Import Information
  • Incident Report - Consumer
  • Incident Report - Industry
  • Label - Marketplace
  • Label - Text
  • Product Specifications
  • Proof of Accreditation
  • Proof of Certification
  • Proof of Standards Compliance
  • Recall - Foreign
  • Storage Information
  • Test data
  • Transport Information
  • Other
• Title
• View attachment
• "X" - delete attachment
• Add another file

8 Administrative Information

• How did you become aware of Consumer Product Incident Reports?
  • Health Canada Website
  • Other Web Search
  • Health Care Professional
  • Public Promotion (e.g. Teddybear Picnic)
  • Other
• Have you reported this incident to the manufacturer or retail store?
  • No
  • Yes - Manufacturer
  • Yes - Retailer

How to submit your incident report:

1. Save the report and submit it online:

To submit online follow these instructions:

• Ensure your internet connection is active.
• Click on the <<Submit Online>> button.
• The form will check mandatory fields and maximum file size (100MB)
• The form will connect to Health Canada's web site and get a Submission Number
• You will be prompted to save you file on your local computer
• The Internet browser will then open to the Submit Incident Report form secure web page.
  • If the browser does not launch - go to https://webprod4.hc-sc.gc.ca/Upload-Televersement/index-eng.jsp
• Select your newly saved report and upload it.
• If the upload is successfully completed a confirmation message is displayed.
• Once you have the confirmation, you are done. Close the browser and close the report.

Please note, if you choose to submit this report online, Health Canada does not guarantee the security of your information while it is travelling over the Internet.

2. Save the report, burn to CD/DVD and submit by post.

Mail/courier the CD/DVD to:

Incident Report - Consumer Product Safety Directorate
Health Canada
123 Slater Street
Ottawa, ON, Canada, K1A 0K9
Address Locator: 3504D

3. Save the report, print and submit by post.

Mail/courier the printed report to:

Incident Report - Consumer Product Safety Directorate
Health Canada
123 Slater Street
Ottawa, ON, Canada, K1A 0K9
Address Locator: 3504D