1. Reporter Information

2. Food Product Details

Product Name: * Type of Food Product: * Select product type Packaged Food Fresh Food Dairy Products Beverages Snacks Sweets/Confectionery Spices/Condiments Oils/Fats Meat/Fish Fruits/Vegetables Bakery Items Baby Food Health Supplements Other Brand Name: Manufacturer Name: * Batch Number/Lot Number: Manufacturing Date: Expiry Date: Price Paid: Package Size/Weight:

3. Food Safety Issue Details

Type of Food Safety Issue: * Select issue type Foreign Objects in Food Unusual Taste Unusual Smell/Odor Unusual Appearance/Color Expired Product Incorrect/Misleading Labeling Poor Quality/Spoiled Suspected Chemical Contamination Suspected Artificial Colors/Additives Packaging Issues Food Poisoning/Illness Adulterated Ingredients Unhygienic Conditions Other Date Issue Discovered: * Time Issue Discovered: Detailed Description of Issue: * Was the product consumed? Select status Yes – Fully consumed Yes – Partially consumed No – Not consumed No – Stopped after noticing issue Is the remaining product available? Select option Yes – Product available for testing Yes – Packaging available No – Product disposed No – Product finished

4. Purchase Details

Where was the product purchased? * Type of Retailer: * Select retailer type Supermarket/Department Store Local Grocery Store Street Vendor Online Platform Restaurant/Eatery Wholesale Market Pharmacy Other Date of Purchase: Do you have the purchase receipt? Select option Yes – Physical receipt Yes – Digital receipt No – Receipt not available No – Receipt lost Retailer Contact Information:

5. Health Impact Assessment

Did anyone experience health issues after consuming this product? Select option Yes – Health issues occurred No – No health issues Not consumed – Cannot assess

6. Witnesses Information

7. Evidence

Upload Evidence Files: Description of Evidence:

8. Impact Assessment

Impact on Consumer: Financial Loss (if any): Potential risk to public safety: Select risk level High – Widespread health risk Medium – Localized risk Low – Individual case Unknown Are you aware of similar complaints about this product? Select option Yes – Heard from others Yes – Seen online reviews Yes – Media reports No – First time hearing Unknown

9. Previous Actions Taken

10. Additional Information

Any Other Relevant Information: What outcome are you seeking? Urgency Level: Normal High – Health risk involved Critical – Immediate danger to public Preferred Method of Contact (if not anonymous): Email Phone Postal Mail No contact preferred

11. Security Verification

12. Declaration