Vape Product Ingredient Report Form
Report the ingredients and composition details for a vape product, including product identification, ingredient breakdown, nicotine content, and any safety notes.
Reporter Information
Reporter Name
*
Organization/Company
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Product Identification
Product Name
*
Product Type
*
Disposable Vape
Refillable E-Liquid
Pod Cartridge
Prefilled Cartridge
Concentrate
Other
Manufacturer / Brand Name
*
Flavor Name
Batch / Lot Number
Date of Report
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Ingredient Composition
Ingredient List
*
Does the product contain nicotine?
*
Yes
No
Unknown
Nicotine Strength
Nicotine Units
Known Allergens or Sensitizers
Known Contaminants or Impurities
Safety Warnings, Testing Notes, or Additional Observations
Submit Report
Should be Empty: