Product Complaint Form

1

Complainant Info

2

Product Info

3

Complaint Details

Section I: Complainant Information

Complainant Profession

Other Complainant Profession

Name of Complainant

Phone Number

Email Address

Date of Complaint

Country

Section II: Product Information

1. Product Name

Rewrite Product & Company Name

2. Dosage Form

Other Dosage Form

3. Strength

4. Batch / Lot Number

5. Expiry Date

Section III: Complaint Details

Complaint Category

Product Quality Complaint

Broken Unit Discoloration Change in taste or odor Contamination Foreign Particle Others

Packaging Defect

Damaged Packaging Missing Unit Others

Labeling Error Suspected Counterfeit

Other

Description of Complaint

Additional Comments

Quantity Affected Single UnitMultiple UnitsUnknown

Sample Available for Investigation YesNo

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2. Allowed formats: JPG, PNG, PDF, DOC, DOCX

3. Maximum file size: 5MB each

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