Product safety complaint Telephone Interpreter Service

If you have difficulty understanding English, contact the

Translating and Interpreting Service (TIS) on 131 450 (for the
By completing this Product Safety Complaint form it will allow
cost of a local call) and ask to be put through to an Information
Consumer Affairs Victoria to investigate the safety issues you
Officer at Consumer Affairs Victoria on 1300 55 81 81.
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
 Motor vehicle design (VicRoads)
 Gas or electrical safety (Energy Safe Victoria)
 Therapeutic goods (Therapeutic Goods Administration)
 Food and drugs (Department of Human Services).

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Fields marked with an * are mandatory. 3. Incident and injury details
Please describe the incident. Include the date it occurred if
1. Your details known*

Preferred title*

Given name*

Family name*

Postal address*

Suburb*
Was there an injury as a result of the incident?*
Postcode*
Yes No
Daytime telephone*
Describe the injury
Mobile telephone

Email address*

2. Details of the product

Product brand name and model number*

What was the age of the injured person at the time of the
Description of the product*
injury?

Was a doctor’s visit required?

Price of the product* Yes No

Was hospital admission required?

Date of purchase* Yes No

4. What action has been taken?

Where was it purchased?* Have you contacted the retailer?*

Yes No

Name of the person you contacted

Manufacturerorimporter(ifknown)
Company/business name

Country of manufacture (if known)

Street address
What standards number or certification marks (eg ‘S’ mark) are
shown (if any)?
Suburb

Postcode

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Date you made the contact 6. Attach supporting documents
If you have supporting documents please attach them to this
form. You can include up to five documents with your complaint.

What was their response? Send this completed form, including any copies of your
documents to
Consumer Affairs Victoria
GPO Box 4567
Melbourne Victoria 3001

Declaration
I declare that the above information is true and correct to the
best of my knowledge. I agree that the information I have given
Have you contacted the distributor?* in this form and any attached documents may be used or
disclosed by Consumer Affairs Victoria to the trader I am
Yes No making this complaint about and all other parties involved in this
complaint.
Name of the person you contacted
Signature

Company/business name

Name

Street address
Date

Suburb
Privacy
Postcode
Consumer Affairs Victoria collects and handles your personal
information consistent with the requirements of the Privacy &
Date you made the contact
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
What was their response?
Agencies. For more information, view the Privacy statement
page on the Consumer Affairs Victoria website
(consumer.vic.gov.au/privacy).

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.

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