Product safety complaint

By completing this Product Safety Complaint form it will allow Consumer Affairs Victoria to investigate the safety issues youraise. Fill out as much of the form as you can – this will help us process your complaintquickly.

If your complaint deals with any of the following product safety issues, please visit the regulated authorities (listed in brackets) for more information

  • Motor vehicle design(VicRoads)
  • Gas or electrical safety (Energy SafeVictoria)
  • Therapeutic goods (Therapeutic GoodsAdministration)
  • Food and drugs (Department of Human Services).

TelephoneInterpreterService

IfyouhavedifficultyunderstandingEnglish,contacttheTranslatingandInterpretingService(TIS)on131450(forthecostofalocalcall)andasktobeputthroughtoanInformationOfficeratConsumerAffairsVictoriaon1300558181.

Fields marked with an * aremandatory.

1.Your details

Preferred title*
Givenname*
Familyname*
Postal address*
Suburb*
Postcode*
Daytime telephone*
Mobiletelephone
Emailaddress*

2.Details of the product

Product brand name and model number*

Description of the product*

Price of the product*

Date of purchase*

Where was it purchased?*

Manufacturer or importer (if known)

Country of manufacture (if known)

What standards number or certification marks (eg ‘S’ mark) are shown (if any)?

3.Incident and injury details

Please describe the incident. Include the date it occurred if known*

Was there an injury as a result of theincident?*

Yes / No

Describe the injury

What was the age of the injured person at the time of the injury?

Was a doctor’s visitrequired?

Yes / No

Was hospital admissionrequired?

Yes / No

4.What action has been taken?

Have you contacted the retailer?*

Yes / No

Name of the person you contacted

Company/business name

Street address
Suburb
Postcode

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Date you made the contact

What was their response?

Have you contacted the distributor?*

Yes / No

Name of the person you contacted

Company/business name

Street address
Suburb
Postcode

Date you made the contact

What was their response?

5.Evidence

Do you have a sample of the product available for us to review if required?

Yes / No

Do you have any written documents to support your complaint?*

Yes / No

Relevant documents are those that provide evidence of the transaction, for example receipts, contracts, quotes, invoices,correspondence,emails, documents you have served on the trader/supplier or they have served on you, advertisements, copies of web pages.

If no, go straight to the Declaration and Privacy Statements then submit your form.

6.Attach supporting documents

If you have supporting documents please attach them to this form. You can include up to five documents with yourcomplaint.

Send this completed form, including any copies of your documents to

Consumer AffairsVictoria
GPO Box 4567
Melbourne Victoria3001

Declaration

Ideclare that the above information is true and correct to the best of my knowledge. I agree that the information I have given in this form and any attached documents may be used or disclosed by Consumer Affairs Victoria to the trader I am making this complaint aboutand all other parties involved in this complaint.

Signature

Name

Date

Privacy

Consumer Affairs Victoria collects and handles your personal information consistent with the requirements of the Privacy & Data Protection Act 2014. Where you do not provide the information required by this form, we may refuse or be unable to process this transaction. We may need to disclose your personal information to other State and Commonwealth Agencies. For more information, view the Privacy statement page on the Consumer Affairs Victoria website (consumer.vic.gov.au/privacy).

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