Pandemic Supply Concern/Complaint Form

We have implemented a process to receive, evaluate, investigate and report any concerns/complaints received in regards to pandemic supply (i.e., PPE, swabs, media, vaccine ancillary supplies, etc.) distributed by the Government of Ontario. The sourcing of pandemic supply is conducted by multiple organizations, primarily Ontario Health, the Ministry of Health, and the Federal Government. Should you have a concern/complaint about a product received from the Government of Ontario, please fully complete and submit this form. Thank you.

Customer Information

Name*

Institution / Facility / Organization Name*

Title

Email*

Phone Number*

Type of Organization*

Select

Organization Type - Other

Please describe.

Department - Unit

Affiliation

Ex: Union name, municipality name, professional body (CNO, OMA)

Address

City*

Region

Please select the region to which your organization belongs.

Select

Product Information

Product Type*

Select

Manufacturer/Brand Name*

This is the manufacturer and/or brand name on the product packaging. If unsure, write not sure.

Manufacturer/Brand Product Code

This is the manufacturer and/or brand product code on the product packaging. If unsure, write not sure.

Product Expiration Date

Lot/Serial Number

This is the lot/serial number on the product packaging. If unsure, write not sure.

Product Concern/Complaint Information

Date concern/complaint noted*

Please enter the date when the concern/complaint was noted by your organization.

Concern/Complaint*

Select

Quantity of Counterfeit Product Quarantined (Box)

How many boxes of suspected counterfeit product do you have quarantined?

Did use of product result in a negative event with client (ex. patient, staff)?

If a negative event occurred, please include a detailed description in the "Description of the concern/complaint" field below. This information is used for tracking purposes only.

Select or enter value

Client Affected by Event

Select or enter value

Concern/Complaint Type - Other*

Description of the concern/complaint*

How was the concern/complaint detected?*

How long has the product been in use at your facility prior to this concern/complaint?

Unusual circumstances?

Select

Details of unusual circumstances

Please upload image(s) of product and package to show labeling information

Packing Slip Attached

Please check this box if you have included a photo or scan of the packing slip below.

File Upload

Drag and drop files here or

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