Corporate PIR - EN - Final - COPY

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Reported By

Name*

First Name

Last Name

Company

Address 1

Address 2

Postal/Zip

City

Country

State

Province

Email*

Phone XXX XXX XXXX*

Language*

Product User

Click if the same as above*

Yes No

Name

First Name

Last Name

Company

Address 1

Address 2

Postal/Zip

City

Country

States

Provinces

Phone

Language

Product Information

Product Description*

Is product CSA Marked?*

Yes No

Does the product contain a CSA Mark?

Is product CSA Marked? - Copy*

Yes No

Does the product contain a CSA Mark?

Is package CSA Marked?

Yes No

Country of Manufacture

Where was the product used?*

CSA File Number

This is the number that appears close (usually below) to the CSA Marks.

Product Identification*

(E.g. Model/Series/Type)

Serial Number

Date of Manufacture

Manufacturer*

Brand Name

Terms & Conditions

*CSA Group conducts investigations solely in support of our certification and standards writing process. I understand that CSA Group is not at liberty to release results of their investigations or the corrective action taken as they are considered confidential.

Legal Terms

By completing this form, I consent to CSA Group collecting and using the information provided by me on this form strictly to conduct investigations into the product incident described. If appropriate and applicable, i understand that it is my responsibility to obtain the consent of individuals whose personal information I am disclosing to CSA Group.

CSA Group is committed to protecting the privacy of the personel information in this form. This information is never sold to third parties by CSA Group. However, I understand and consent to CSA Group releasing any personal information contained on this form to manufacturers or regulatory authorities for the purpose of investigating a product incident (only to the extent required for such investigation); or to comply with a court order requiring release.

Visit CSA Group´s Corporate Policy Confidentiality and Privacy at Legal for information on how CSA Group protects your personal information.

Reported By

Product User

Product Information

Incident Details

Terms & Conditions