Adverse Event Report

Consumer Information

Please provide your personal details so we can follow up if needed.

Full Name *

Email *

Phone

Date of Birth

Address

City

State

Postal Code

Age

Sex

Male

Female

Weight

lbs

kg

Race

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

Skin Type

Dry

Oily

Combination

Skin Reactivity

Sensitive

Reactive

Non Sensitive

Adverse Event Information

Describe the adverse event or product issue you experienced.

What happened when you used the product? *

Had a bad side effect (including new or worsening symptoms)

Used a product incorrectly which could have led to a problem

Noticed a problem with the quality of the product

Did any of the following occur?

Death

Life-threatening experience

Hospitalization

Required intervention to prevent impairment

Significant disfigurement

Congenital anomaly / Birth defects

Infection

Other / None

When did the event occur? *

Symptoms

Describe the event and how it happened *

Are you allergic to any medications, food or other products?

Other diagnosed illnesses / medical history / chronic health conditions

Relevant test / laboratory data / medical advice regarding adverse effect

Upload supporting images

Product Information

Details about the MY.ORGANICS product involved in the event.

Brand Name

Product Name *

Have you used any other product of this brand?

Date of First Use

Date of Last Use

Do you still have the product?

Yes

No

Do you have a picture of it?

Yes

No

Is it labeled for single use?

Yes

No

Expiration Date

Product Identifier (EAN)

Batch Number

Event reappeared after reintroduction?

Yes

No

Does not apply

Please add detail of the area of use

Have you used any other cosmetic products?

Have you changed your skincare routine or products in recent times?

Retailer Information

Where did you purchase the product?

Retailer Name