REACTION REPORT
FOR OFFICE USE ONLY:
ATTENTION:
TRACKING NUMBER:
DATE RECEIVED:
PLEASE NOTE:
1.
All sections of this form (5 pages) must be CLEARLY PRINTED in detail to
prevent delays. The inability to read the report will result in delays.
2.
Both the reaction report form and product(s) are to be sent to the Quality
Assurance Manager at the factory via the relevant distributor. They are to
be delivered in a white Environ® packet, the reaction report form MUST
accompany the returned products.
3.
For LOCAL SOUTH AFRICAN DISTRIBUTORS: This reaction report form is
to be received by the Quality Assurance Manager no more than 5 DAYS
after the reaction occurred.
4.
For INTERNATIONAL DISTRIBUTORS: A copy of the reaction report form is
to be sent to Dr. Ernst Eiselen at advisor@environ.co.za
5.
If possible, kindly attach clear photographs of the reaction as well as the
date the photos were taken.
PLEASE COMPLETE THE FOLLOWING:
DATE OF COMPLAINT:
DISTRIBUTOR:
DETAILS OF PRODUCT/S THAT ARE BEING RETURNED:
Name of product:
Batch number:
Expiry Date:
CONTACT DETAILS OF THE PERSON WHO SOLD YOU THE ENVIRON®
PRODUCTS:
TYPE OF STOCKIST:
DIRECT AGENT
SALON
NAME OF PERSON:
NAME OF SALON (if applicable)
TEL:
FAX:
CELL:
CLIENT’S DETAILS:
NAME:
TEL:
FAX:
CELL:
GENDER:
MALE
FEMALE
AGE: (Please tick the relevant square)
Under 20
20 – 29
30 – 39
40 - 49
50 – 59
Over 60
Please answer all questions:
COLOUR OF EYES:
COLOUR OF HAIR:
TYPE OF SKIN:
IS YOUR SKIN:
I – VERY PALE
II - PALE
III – MODERATE
IV – MEDITERRANEAN
V - LIGHT BROWN
VI - DARK BROWN
OILY
DRY
NORMAL
COMBINATION
HAVE YOU EVER EXPERIENCED ANY REACTION TO ANY OTHER COSMETIC
PREPARATIONS - OTHER THAN ENVIRON®? (If so, please state which products
and what happened)
HAVE YOU EVER HAD ANY REACTION TO SUN BLOCKING AGENTS? (State the
name of the product and describe the reaction)
ARE YOU TAKING ANY MEDICATION AT PRESENT? (If so please list below)
DO YOU HAVE ANY KNOWN ALLERGIES OR REACTIONS?
(e.g. earrings, soaps, etc.) Please specify:
DO YOU SUFFER FROM ECZEMA OR ASTHMA?
YES
NO
HAVE YOU BEEN TREATED FOR ACNE OR PIMPLES IN THE PAST?
YES
NO
If yes, please describe the treatment:
DO YOU GET PRE-MENSTRUAL SPOTS?
YES
NO
PLEASE LIST ALL THE ENVIRON® PRODUCTS SOLD TO YOU WHEN YOU FIRST
BECAME AN ENVIRON® CLIENT:
PLEASE LIST ALL THE ENVIRON® PRODUCTS YOU ARE CURRENTLY USING:
WHEN THE REACTION OCCURRED WERE YOU ALSO USING ANY OTHER
COSMETIC BRANDS IN CONJUNCTION WITH ENVIRON®?
If yes, please specify:
WHICH COSMETICS WERE YOU USING BEFORE YOU STARTED USING
ENVIRON®?
HOW LONG HAVE YOU USED ENVIRON® PRODUCTS?
FIRST TIME USER
LESS THAN 6 MONTHS
6 MONTHS –1 YEAR
LONGER THAN 1 YEAR
TO WHICH PRODUCT(S) DO YOU THINK YOU REACTED?
WHAT WERE YOUR IMMEDIATE SYMPTOMS?
REDNESS
SKIN SENSITIVITY
ITCHING
ACNE REACTION
SKIN FLAKING
OTHER (PLEASE SPECIFY)
HOW SOON AFTER THE FIRST APPLICATION DID THIS OCCUR?
HOW LONG DID THE REACTION LAST?
HOW WAS THE REACTION RELIEVED AND WHAT ADVICE WERE YOU GIVEN BY
YOUR STOCKIST?
DID YOU HAVE TO SEE A DOCTOR FOR TREATMENT? YES
If yes, please list the treatment prescribed:
ANY OTHER INFORMATION THAT MIGHT BE RELEVANT:
NO
SIGNATURES:
CLIENT:
SUPPLIER:
DATE:
Thank you for your co-operation. You will be contacted shortly.
TRAINING MANAGER ONLY:
DOES THE PRODUCT NEED TO BE TESTED? YES
NO
QUALITY CONTROL MANAGER ONLY:
HAS THE PRODUCT BEEN SENT TO THE FACTORY FOR TESTING?
YES
NO
If No, please give reason why:
HAS THE PRODUCT BEEN REPLACED OR REFUNDED?
REFUNDED
REPLACED
NAME OF PERSON WHO DEALT WITH THE OUTCOME OF THE REACTION:
WHAT ACTION WAS TAKEN BY THE PERSON NAMED:
QUALITY CONTROL- CUSTOMER COMPLAINT FORM
DATE RECEIVED:
CUSTOMER’S NAME:
STOCKIST’S NAME:
DISTRIBUTOR’S NAME:
PRODUCT:
BATCH NO:
COMPLAINT:
HAS THIS PRODUCT BEEN:
REFUNDED
REPLACED
TO WHOM WAS THE REPLACEMENT OR REFUND MADE?