CODD Reporting Form

This is a confidential reporting form; CIPH will be removing all company names and only reporting the key issues. Contact information is only retained for CIPH follow-up and reporting.

Source of Report:

Consumer
Jurisdictional Authority
Date Submitted:	Date:
Name:
Title:
Address:
Phone Number:
Fax Number:
Email:

Product Information:

Product Information:
Product Type:
Manufacturer:
Model/Catalogue:
Marking in Question:
Place of Purchase/Sale:
Name:
Address:
Phone:
Contact Person:
Listing Mark Information:
Mark is on:	Product Package Literature
Nature of Problem:

For Use by Inspector:

Jurisdiction:
Is the job on hold?	Yes No

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