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Problem Report Form
The Problem Report Form is for users to provide the information necessary to ensure
that the process of inspecting and repairing the problem can be performed smoothly.
Please complete the form in as much detail as possible. Please also include this
Problem Report Form with your shipment when requesting repairs.
DAS-100 Semi-Active Sampler Problem Report Form
If a problem occurs, please copy and fill out this Problem Report Form and contact your
Sibata representative or the store where you purchased the product.
Date completed:
(yyyy/mm/dd)
Circumstances Under Which the Product Is Used
Purchase date:
(yyyy/mm/dd)
Date of first use:
(yyyy/mm/dd)
Frequency of use:
: Daily
:
days a week
:
days a month
Hours of use per day:
Temperature of operating environment (actual measurements, if possible):
Between _____ and _____
°
C
Number of units owned:
Used for:
Problem Description
Problem frequency:
: Every time
: Occasionally
: Rarely
: Other (
)
Timing of occurrence:
: Immediately after purchase
: Within 1 month
: Within 1 week
: Other (
)
Symptoms (in as much detail and as specifically as possible):
Example: The LED flashes erratically during operation.
Check List
(circle all applicable)
x
Does the unit function when a battery is installed?
(Only the fan functions / Only the LED illuminates / Neither the fan or LED functions /
The LED and fan function, but do not stabilize)
x
Is the unit rusty, corroded, or dirty? (Yes / Not very much)
x
Is the unit being used in an environment containing significant levels of chemicals?
(Yes / No)
x
Does the unit show any signs of being dropped or impacted?
(Yes / No)
Check List for Requesting Repairs
: Fill out a copy of the Problem Report Form and include it inside the shipping box.
: If the intake of a hazardous substance is possible, place this form in an envelope
and affix it to the shipping box exterior. Please make a note of that accordingly.
Summary of Contents for DAS-100
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