Consumer Form for filing Adverse Event
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*
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1
Consumer Details
2
Event Information
3
Product Information
4
Review and Confirm
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Notification Email (Owner)
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Fetched Email Addresses
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Company Name
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User ID
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CD Record Number
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Dropdown
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Product name text
Consumer Information
Please enter the contact information for the person who experienced the adverse event.
Consumer Name
*
Consumer Email
*
Consumer Phone
*
Consumer Address 1
Consumer Address 2
Consumer City
*
Consumer State
*
Consumer Postal Code
Consumer Date of Birth
*
Please enter the date in MM/DD/YYYY format.
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Consumer Date of Birth
*
Please enter the date in MM/DD/YYYY format.
MM slash DD slash YYYY
Sex
Please Select
Male
Female
Non-binary and/or Intersex
Decline to answer
Gender
Please Select
Cisgender man/boy (gender corresponds with birth sex)
Cisgender woman/girl (gender corresponds with birth sex)
Transgender man/trans man/ female-to-man (FTM)
Transgender woman/trans woman/male-to-female (MTF)
Decline to answer
Other gender category
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Please specify gender
*
If other please specify
*
Include as many details as possible
Weight
Weight Unit
Lbs
Kg
Race
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Ethnicity
Please Select
Hispanic or Latino
Not Hispanic or Latino
Person reporting this information is different than the consumer above
Person reporting this information is different than the consumer above.
Reporter Information
Please enter the contact information the person reporting the adverse event.
Same as Consumer
Use consumer address information.
Are you a health professional?
Yes
No
Also sent the report to FDA?
Yes
No
Unknown
Reporter First Name
*
Reporter Last Name
*
Reporter Email
*
Reporter Phone
*
Reporter Occupation
Please Select
Administrator/Supervisor
Biomedical Engineer
Dentist
Non-Health Professional
Nurse
Nurse Practitioner
Other Health Professional
Pharmacist
Physician
Physician Assistant
Risk Manager
Third Party Servicer
Reporter Address 1
Reporter Address 2
Reporter City
*
Reporter State
*
Reporter Postal Code
Adverse Event Information
About the Problem
(Check all that apply)
Had a bad side effect (
including new or worsening symptoms
)
Used a product incorrectly which could have led to a problem
Noticed a problem with the quality of the product
Did any of the following occur?
*
(Check all that apply)
Life-threatening experience
Hospitalization (initial or prolonged)
Required intervention to Prevent Permanent Impairment/Damage
Significant disfigurement
Serious and persistent rashes
Second or third degree burns
Significant hair loss
Persistent or significant alteration of appearance
Congenital anomaly/Birth Defects
Infection
Death
Other
Date of Demise?
*
Please enter the date in MM/DD/YYYY format.
Other
*
When did this event occur?
*
Please enter the date in MM/DD/YYYY format.
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When did this event occur?
*
MM slash DD slash YYYY
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Product Information
*
Product Name
Describe the event and how it happened
*
Include as many details as possible
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Are you allergic to any medications, food or other products
Are you allergic to any medications, food or other products
Other diagnosed illnesses / medical history / chronic health conditions
Relevant Test/Laboratory Data
Upload Test or Lab Reports
Drop files here or
Select files
Accepted file types: jpg, jpeg, png, pdf, doc, Max. file size: 256 MB.
Product Information
Product Name
*
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Brand Name
*
Product Name
*
Please Select
Boo Lice Scaring Shampoo
Boo Lice Scaring Spray
Curl Leave In Conditioner
Curl Shampoo
Curl Conditioner
Curl Volumizing Foam
3 in 1 Shampoo, Conditioner, Wash
Detangler
Sensitive Styling Foam
Wash Plus Shampoo
Multi Styler
Swim 3 in 1
Swim Leave In Conditioner
Hair Styling Stick
Curl Defining Cream
Honey Plus Almond Curl Cream
Antihumidity Spray
Color Glossy Black
Color Glossy Auburn
Color Glossy Dark Brown
Color Glossy Medium Brown
Color Glossy Light Brown
Color Glossy Medium Blonde
Color Glossy Silver
Soothing Bubble Bath
Moisturizing Bubble Bath
Coconut Cream Intense Repair Conditioner
Tzatziki Taming Spray Leave In Conditioner and Detangler
Guacamole Hair Wax Stick
Sparkling Apple Cider Clarifying Scalp Treatment
Honey Chia Smoothing Curl Mask
Rouge Cloud Hair Fragrance
Rosemary Mint Hair Oil
Guacamole Whip Bond Repairing Spray Hair Mask
Guacamole Whip Deep Moisture Condtioner
Jasmine Bliss Hair Fragrance
Guacamole Gloss
Guacamole Whip Deep Moisture Shampoo
Creme Brulee Curl Custard
Hot Sauce Thermal Protectant Spray
Goddess Hair Fragrance
Guacamole Whip Deep Moisture Mask
Chimichurri Mint Tingle Intense Repair Shampoo
Guac Twist Hair Fragrance
Honey Plus Shea Shampoo
Honey Plus Coconut Conditioner
Honey Plus Biotin Leave In Spray Mask
Brand Name
*
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Manufacturer
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Packer
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Distributor
Date of first use?
Please enter the date in MM/DD/YYYY format.
Date of last use?
Please enter the date in MM/DD/YYYY format.
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Date of first use?
MM slash DD slash YYYY
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Date of last use?
MM slash DD slash YYYY
Do you still have the product?
*
Yes
No
Do you have a picture of the product?
Yes
No
Front and Back of Label
*
Drop files here or
Select files
Accepted file types: jpg, jpeg, png, doc, Max. file size: 256 MB.
Is this product labeled for single use?
Yes
No
Expiration Date
Please enter the date in MM/YYYY format.
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Expiration Date
MM slash DD slash YYYY
Product Identifier
Product Batch No.
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Serial Number
Event reappeared after reintroduction?
Yes
No
Does not apply
Retailer Information
Retailer Name
Retailer Address 1
Retailer Address 2
Retailer City
Retailer State
Retailer Postal Code
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Retailer Website
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Retailer Phone
Review And Confirm
Consumer Information
Reporter Information
Event Information
Product Information
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