Voluntary supplier report

1. Contact details
2. Product details
3. Injury & incident details
4. Preview & submit
5. Complete

You can use this form to make a voluntary report to the ACCC about a safety incident, situation or concern involving a consumer good or product-related service that you supply (and does not require a mandatory report).

Who should use this form
This form is for suppliers of consumer goods (such as retailers, wholesalers, distributors, importers or manufacturers) or product related services (such as installers, repairers, cleaners, transporters or assemblers of consumer goods).
Before completing this form, please read our Privacy Statement.

What to voluntarily report

Voluntary supplier reports about safety incidents, situations and concerns may help prevent future deaths or serious injuries or illnesses. The ACCC will assess your voluntary supplier report and only contact you if it requires additional information or if there is a need to mitigate any potential hazards or risks. Below is a non-exhaustive list of situations that the ACCC strongly encourages you to voluntarily report:

the consumer product did not cause a death or serious injury or illness in this instance, but had the potential to do so with a slight change in circumstances (such as a near miss)
the injury or illness is serious but developed slowly over time (not acute)
a person’s pre-existing ailment, disorder, defect or morbid condition contributed to the death or serious injury or illness
the serious injury or illness was treated by a health practitioner who is not a medical practitioner or a nurse
the incident in question was caused by a person misusing the consumer good in an unforeseeable way.

Who should NOT use this form

As a supplier, if you become aware of a death or serious injury or illness associated with a consumer good or product related service you supply, you must submit a mandatory report to the Commonwealth Minister.

You can submit a mandatory report by filling out an online form available at www.productsafety.gov.au/mandatoryreporting.
If you are a consumer wanting to report a possible safety issue with a consumer good, please fill out the ‘Report an Unsafe Product’ form available at www.productsafety.gov.au/contact-us/for-consumers/report-an-unsafe-product

Contact details

The ACCC will contact this person for additional information if required.

Title

First name

Last name

Phone number

Email address

Do you use a TTY (Telephone Typewriter)?

YesNo

Address

Address 2

City

State

Post code

Country

Supplier name

Product details

Full name of the product

Product category

Product description

(including intended use of product, product’s country of origin,where the product was supplied and any identifying numbers) *

Is this product subject to a recall in Australia?

PRA number

Injury & incident details

Which of the following situations best describes the safety concern you are voluntarily reporting? *

The consumer product did not cause a death or serious injury or illness in this instance, but had the potential to do so with a slight change in circumstances (such as a near miss)

The injury or illness is serious but developed slowly over time (not acute)

A person’s pre-existing ailment, disorder, defect or morbid condition contributed to the death or serious injury or illness

The serious injury or illness was treated by a heath practitioner who is not a medical practitioner or a nurse

The incident in question was caused by a person misusing the consumer good in an unforeseeable way

Other

Describe the safety concern

What action(s) have you taken or do you intend to take in relation to the product or service?

Photographs or other supporting information

Please review your information before submitting it to the ACCC.

Your voluntary supplier report

Consent to disclose

To process your voluntary report it may be necessary for us to share the information you have provided with other goverment agencies in Australia. Read our privacy policy (opens in a new window) for more information.

I consent to the disclosure of this notice to one or more of the following government regulators on the understanding that any such disclosure will continue to be treated as confidential by the receiving party:

Therapeutic Goods Administration (for notices relevant to therapeutic goods);

Australian Pesticides and Veterinary Medicines Authority (for notices relevant to pesticides and veterinary medicines);

Food Standards Australia New Zealand (for notices relevant to food) and the following state and territory food regulators: NSW Food Authority, ACT Government Health Directorate, Victorian Department of Health, Queensland Health, SA Department of Health, NT Department of Health & Human Services, Tasmanian Department of Health & Human Services, Department of Health WA;

Ministry of Business, Innovation and Employment (for notices relevant to product safety in New Zealand);

The Department of Infrastructure, Regional Development and Cities (for notices relevant to motor vehicles);

Electrical Regulatory Authorities Council (ERAC), Energy Safe Victoria, Queensland Electrical Safety Office, Queensland Petroleum and Gas Inspectorate, Office of the Technical Regulator South Australia, NT WorkSafe, EnergySafety WA, ACT Planning and Land Authority, Workplace Standards Tasmania (for notices relevant to gas or electrical safety);

Staff of ACT Office of Regulatory Services, NSW Fair Trading, QLD Office of Fair Trading, SA Attorney General's Department, TAS Consumer Affairs and Fair Trading, VIC Consumer Affairs and WA Department of Commerce (for notices relevant to incidents that occurred in these jurisdictions).

I give consent to disclose