Consumer Product Incident Report Form for Fire and Safety Authorities

Report - Section 1

Report type (required)

Health Canada Case Number E.g. "2022-024561" (required)

Incident - Section 2

Incident Number

Note: Reference number used by your organization

Incident Date(YYYY-MM-DD) (required)

Nature of Incident

Other/not listed

Civilian Injuries (required)

Number of Victims

Was the fire contained within the product?

Property Damage

Estimated Loss

Incident product secured by:

Organization Name

Contact Name

Contact Email (user@example.com)

Incident Details (required)

Product - Section 3

Product Type Involved or Source of Ignition (required)

Manufacturer or Brand

Model/Catalogue Number

Serial Number

Date Code

Listing Mark Information - Section 4

Listing Mark Information {{$index + 1}}

Certification Body

Other Certification body

Mark is on

File Number

Control/Issue Number

Reported By - Section 6

Organization (required)

Name (required)

Title

City

Postal Code

Country

Other Country

Province

State

Region

Email (yourname@domain.com) (required)

Telephone (including area code)

Privacy Notice

I authorize Health Canada to release my personal information to a person or a government that carries out functions relating to the protection of human health or safety and/or to the supplier of the product so that they may evaluate this incident. (required)

Some of the information required may be personal information as that term is defined under the Privacy Act. The personal information requested in this submission is collected under the authority of the Department of Health Act for the purpose of informing a broad range of Health Canada's activities in relation to promotion and preservation of health, including monitoring trends. Personal information that you provide is protected under the provisions of the Privacy Act which also authorizes the disclosure of personal information in certain circumstances. The Privacy Act gives you the right to access and/or to correct your personal information. The personal information and its use is described in Info Source under the Standard Personal Information Bank "Branch Incident Reporting System" (HC PPU 088).

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