— Seeking Assistance in SkaldPillTips Investigation

QUESTIONNAIRE

1. Please indicate which pills you purchased on eBay:

SKALD Fat Burner - Weight Loss Appetite Suppressant Mood & Energy Capsules

Beldt SKALD Fat Burner & Respiratory Support Supplement 60 Capsules

3-Pack PhenQ Ultra Diet Pills Fat Burner, Weight Loss Formula - 180 Capsules

PhenGold Pills, Original Multi-Action Weight

2. When did you make the purchase?

Year / Month / Day

3. Was the bottle sealed in what appeared to be original packaging?

Yes
No

If no, check the items that apply:

Appeared to have been repackaged/not original label

Did not contain label

Contained label for product other than what was purchased

Label appeared to be damaged or misplaced on bottle

Did not have a tamper resistant seal

Contained a number of pills different than what the label indicated or that you ordered

Other

If other, please describe:

4. How many of the pills did you take?

5. How many of the pills did you take daily?

6. Do you have any of the pills left in the original bottle?

Yes
No

7. Did anyone other than you take the pills?

Yes
No

8. Did you experience any unexpected health concerns or side effects from taking the pills?

Yes
No

If yes, please describe:

9. Did you experience any other negative impacts from taking the pills?

Yes
No

If yes, please describe:

10. Do you have any other information related to the use of pills that may be help investigators?

Thank you for your assistance. You will be provided with a case status update when one is available. For case specific questions or to provide additional information, please contact the FBI at SkaldPillTips@fbi.gov.

Privacy Act Statement

The FBI is authorized to collect the information on this form by one or more of the following provisions: Title 28, United States Code, sections 533 and 534; Title 28, Code of Federal Regulations, section 0.85; and the Attorney General Guidelines for Victim and Witness Assistance. The information requested will assist the FBI in providing you with assistance to which crime victims are entitled under federal law. You do not have to provide the requested information; however, failure to do so may hinder the FBI in providing you with crime victim assistance. The information collected on this form is protected by the Privacy Act of 1974, as amended, Title 5, United States Code section 552a, and is maintained in the FBI’s Central Records System, DOJ/FBI-002, a description of which was published in the Federal Register at 63 Fed. Reg. 8671 (Feb. 20, 1998) and which may be viewed at www.justice.gov/opcl/doj-systems-records#doj

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Seeking Assistance in SkaldPillTips Investigation

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