MECAP Report Form

Medical Examiner and Coroner Reporting Form

This is an on-line form which allows Medical Examiners and Coroners to file a MECAP report. If you desire an alternative reporting method, you can report a case by telephone by calling (toll free) (800) 638-8095. Say “This is a MECAP report.” You will then be placed in contact with the MECAP Project Manager for your state, who will ask for the information noted below. You can also send a report by email to hazard@cpsc.gov, or fax it to (800) 809-0924.
When filling out the form, use the TAB key or your mouse to go to the next data area. Use the scroll bar to scroll down the form.

Medical Examiner’s/ Coroner’s Case No:
Medical Examiner’s/ Coroner’s Name:
Date of accident:
Date of death:
Accident location - city:
Accident location - state:

Your Name:
Office:
City:
State:
County:
Telephone:
Email address:

Brief description of accident sequence [please include the age and sex of the victim(s)]:

Name, address and telephone number of any state/local personnel who investigated the accident:

Type of consumer product involved:
Manufacturer and brand name of product:
Product model and serial numbers:
Cause of death:
Is product available for examination?	YesNo
If yes, where?

OMB Control Number 3041-0029

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