Product Safety Concern and Employee Retaliation Report Form
Report a product safety concern, employee retaliation, or both.
Concern type
*
Product safety concern
Employee retaliation
Both
Product name or model
Incident date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location or worksite
*
Describe the product safety concern
*
Did retaliation occur?
*
Yes
No
Not sure
Describe the retaliation concern
*
Is there an immediate safety risk?
*
Yes
No
Not sure
Reporter name
First Name
Last Name
Preferred contact information (work email or phone)
Submit report
Should be Empty: