Product Defectiveness Assessment Questionnaire
Please provide detailed information to help us assess and address product defects effectively.
Your Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Product Name and Model
*
Product Serial Number (if available)
Date of Purchase
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Place of Purchase (Store or Online Platform)
*
Type of Defect Observed
*
Please Select
Physical Damage
Functional Failure
Cosmetic Issue
Missing Parts
Packaging Issue
Other
Please rate the severity and frequency of the defect
*
Rows
Severity
Frequency
Minor
1
2
Moderate
3
4
Severe
5
6
Please rate your satisfaction with the following aspects:
*
Rows
Very Dissatisfied
Dissatisfied
Neutral
Satisfied
Very Satisfied
Product Quality
7
8
9
10
11
Customer Service
12
13
14
15
16
Replacement/Repair Process
17
18
19
20
21
Describe the defect in detail
*
Upload photos or supporting documents (optional)
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