Distributor Customer Feedback Form
Summary
Date Feedback Received: *
MM
/
DD
/
YYYY
Person Providing Feedback to Distributor
Name:
 *
Organisation:
 *
Contact #:
 *
Email: *
Address:
 *
Description
 *

Provide a summary of the feedback reported

If a complaint (negative):

  • Please provide enough information to enable to determine reportable
  • Please provide the serial number/batch number of the product in order to support traceability
Please provide at a minimum - the name, address, and telephone number of the complainant, the product involved, a description of the alleged deficiency, and the nature of any injury/death or potential injury
Feedback:
 *
Required
Is this a Reportable Event
 *

* If UNKNOWN  -  for reportability, seek clarification/review from the TICL Quality, Regulatory & Sustainability Manager.  

Reportable Event:  The Adverse Event Report section will need to be completed to provide more detailed information about the event and any injuries/potential injuries.

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