Xerox WorkCentre 5790 Series, Service Manual

Page: 1607 / 1610

Form EH&
S-
7
0
0
Rev 3.
0 (18 M
a
rch 200
9)
A4 Format
EHS 700 - Health & Safety Incident Report Form
for Incidents Involving a Xerox Product
EH
&S O
ffi
ce
Us
e
ON
LY
EH&S Incide
nt
Refe
re
nce
N
u
mbe
r:
*Date
Of
In
cide
nt
(mm
/ d
d
/ y
y
):
Pr
od
uc
t D
esc
ripti
on
*
Mod
el No.
or Pro
duct Nam
e
:
Product S
erial
Numbe
r
:
Se
rial
N
umb
er(s
) of A
cc
es
so
ry
(ies
):
In
sta
lla
tion Da
te:
To
ta
l Copy
Me
te
r
:
Da
te
of
la
st s
erv
ic
e ma
inte
na
nc
e
:
List damage
d
and aff
ec
te
d part(
s) of
th
e mac
hin
e b
y de
sc
ription and
part numb
er
:
*
Desc
ript
io
n
Part Number
*
Location of prod
uct
and
af
fe
cted part(s):
Cu
st
om
er
Id
en
tifi
ca
tio
n
*
Cust
om
er Na
me:
*
Nam
e
of
Cust
omer Cont
act
Pers
on
:
*
Te
le
phone
:
*Addre
ss:
E-mail:
Fax
:
Cu
stome
r Service Eng
inee
r Identificatio
n
*
Name
(re
q
ui
re
d for Xe
ro
x se
rvi
ce
d
e
q
ui
pme
n
t)
:
Employe
e
:
E-mail
:
Loc
ation
:
*
Phone
(re
q
ui
re
d fo
r Xe
ro
x se
rvi
ce
d
e
q
ui
pme
n
t)
:
In
di
vid
ual Provid
in
g Noti
fic
ati
on
*
Name
:
*
Ti
tle
:
*
Te
le
ph
on
e N
um
ber
:
*
Org
an
izat
ion
:
E-Mail:
Mailing Address
:
*
D
ate Repor
t Sub
m
itted
:
*
Required information is preceeded b
y
asterisk
,
title
shown in red
, turquoise wash background