If you or a
family member have experienced a recent injury involving a consumer
product, please provide the following information and press the
SUBMIT button. We will forward
this data to the Consumer Product Safety Commission.
In the space below, describe
the incident or hazard, including a description of injuries,
answers to the following questions:
Name of victim
(if different from above)
Victim's age at time of incident
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?