Cannabis Reporting Form

Privacy Notice Statement

The personal information you provide is protected in accordance with the Privacy Act and is collected under the authority of Section 4 of the Department of Health Act. Your contact information is being collected to enable Health Canada to follow up with you regarding your report and may be used to initiate an investigation, authorized under Part 7 of the Cannabis Act. The information that you provide may be provided to the party subject to this report or to provincial, territorial or federal regulatory agencies in order to address the matter you have raised. However, the personal information you provide about yourself would not be provided to the party subject to the report without your consent. To safeguard privacy, please ensure that you limit the amount of personal information you provide in the text of your report. For more information please refer to the personal information bank Public Communications PSU 914 at www.infosource.gc.ca. You have the right to access your personal information and correct any incorrect information. You have the right to file a complaint with the Privacy Commissioner of Canada if you think your personal information has been handled improperly. For details regarding the handling of your personal information, please contact Health Canada’s Privacy Management Division at hc.privacy-vie.privee.sc@canada.ca.

Information about who is reporting

Please include details about yourself in this section

Your name (given name and last name)

Who are you

General public
Consumer
On behalf of consumer
Industry
Organization
Province or Territory
Municipality
Media
Retailer
RCMP
Health care practitioner
Pharmacist
Other

Apartment number (if applicable)

Address (number and street)

City

Province

Postal code

Country

Canada
Other

Health Canada may contact you to obtain additional details or clarification about the information you are submitting.

Telephone (including area code)

Fax (including area code)

Reason for report

Is this report related to cannabis for medical or non-medical purposes?

Note to screen readers: The following selection "Report related to" will allow you to pick the topic of your report. If you select "Cannabis product/accessory", it will add 2 sections to this form called “Cannabis product or accessory”. It allows you to enter up to 5 products or accessories and a section called “Where was the cannabis product or accessory purchased”. If you unselect this option, it will remove those sections and any information you may have entered into them.

Report related to

Cannabis product or accessory
Service related to cannabis
Site related to cannabis
Promotion/advertising/marketing related to cannabis
Other

Nature of report (required)

Is the report related to a person under 18 years of age? (required)

Is this report associated with a side effect or injury?

Yes
No
Unknown

Date of cannabis related issue (YYYY-MM-DD)

Describe the issue in detail (required)

Please provide a sufficient description of the cannabis issue that you are experiencing.

Cannabis product or accessory

Enter the product or accessory details and information regarding the party that sold or distributed the cannabis product or accessory as well as where it was purchased. This information can be found on the label of the cannabis product or accessory. To enter additional products or accessories, click on the "Add product/accessory" button. To remove one product and its related information, click on the "Remove product/accessory" button.

Cannabis product (opens new window) means cannabis of only one of the classes that are set out in Schedule 4 (opens new window) to the Cannabis Act – or a cannabis accessory if that accessory contains such cannabis – after it has been packaged and labelled for sale to a consumer at the retail level, but does not include a drug containing cannabis.

Cannabis accessory (opens new window) means

a thing, including rolling papers or wraps, holders, pipes, water pipes, bongs and vaporizers, that is represented to be used in the consumption of cannabis; or
a thing commonly used in the consumption of cannabis that is sold at the same point of sale as cannabis.

Note to screen readers: This section contains 2 buttons labelled "Add product" and "Add accessory". Pressing either button will replace this section with additional form fields. The section will also include a “Remove” button which will remove this new section and replace it with the original buttons. Each new product or accessory added will add additional buttons underneath it to add more products or accessories.

Information regarding the Party Subject to this report

If this report is related to a specific cannabis product or accessory, this information can be found on the label of the cannabis product or accessory.

If this report is associated to a site related to cannabis, a service related to cannabis, a promotion/advertising/marketing related to cannabis, or other, please provide as much information as possible as it relates to the subject of the report.

Name (full legal name – no abbreviations)

Website (if applicable)

Address (number and street)

City

Province

Postal code

Country

Canada
Other

Telephone (including area code)

Fax (including area code)

Was this information reported to the party subject to the report?

Documents and pictures

Please upload any additional information that you wish to include in the Cannabis Reporting Form.

The following file formats are supported: DOC, DOCX, PDF, RTF, XLS, XLSX, BMP, GIF, JPEG, PNG, TIFF.

File Name: (maximum file size of 2MB)

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Date modified:: 2023-10-03

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