Product safety complaint
By completing this Product Safety Complaint form it will allow
Consumer Affairs Victoria to investigate the safety issues you
raise. Fill out as much of the form as you can – this will help us
process your complaint quickly.
If your complaint deals with any of the following product
safety issues, please visit the regulated authorities (listed in
brackets) for more information:




Telephone Interpreter Service
If you have difficulty understanding English, contact the Translating
and Interpreting Service (TIS) on 131 450 (for the cost of a local call)
and ask to be put through to an Information Officer at Consumer
Affairs Victoria on 1300 55 81 81.
Motor vehicle design (VicRoads)
Gas or electrical safety (Energy Safe Victoria)
Therapeutic goods (Therapeutic Goods Administration)
Food and drugs (Department of Human Services).
(02/2016)
consumer.vic.gov.au
Page 1 of 3
Fields marked with an * are mandatory.
3. Incident and injury details
1. Your details
Please describe the incident. Include the date it occurred if
known:*
Preferred title:*
Given name:*
Family name:*
Postal address:*
Suburb:*
Postcode:*
Was there an injury as a result of the incident?*
Yes:
Daytime telephone:*
Mobile telephone:
No:
Describe the injury:
Email address:*
2. Details of the product
Product brand name and model number:*
Description of the product:*
What was the age of the injured person at the time of the
injury?
Was a doctor’s visit required?
Price of the product:*
Yes:
No:
Was hospital admission required?
Date of purchase:*
Where was it purchased?*
Yes:
No:
4. What action has been taken?
Have you contacted the retailer?*
Yes:
No:
Name of the person you contacted:
Manufacturer or importer (if known):
Company/business name:
Country of manufacture (if known):
What standards number or certification marks (eg: ‘S’ mark)
are shown (if any)?
Street address:
Suburb:
Postcode:
Page 2 of 3
Date you made the contact:
6. Attach supporting documents
What was their response?
If you have supporting documents please attach them to this
form. You can include up to five documents with your
complaint.
Send this completed form, including any copies of your
documents to:
Consumer Affairs Victoria
GPO Box 4567
Melbourne Victoria 3001
Declaration
Have you contacted the distributor?*
Yes:
I declare 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 about and all other parties involved in
this complaint.
No:
Name of the person you contacted:
Company/business name:
Signature:
Street address:
Name:
Suburb:
Date
Postcode:
Date you made the contact:
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).
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.
Page 3 of 3