Xerox WorkCentre 6605, Service Manual

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Phaser 6600 and WorkCentre 6605 Xerox Internal Use Only
Service Manual
A-8
Form EH&S-700 Rev 3.0 (18 March 2009) North America Letter Format
EHS 700 - Health & Safety Incident Report Form
for Incidents Involving a Xerox Product
For incidents in Canada:
PIPEDA consent given
YES NO
EH&S Office Use ONLY
EH&S Incident Reference Number:
PIPEDA is the Canadian “Personal Information Protection and Electronic Documents Act.”
*Date Of Incident (mm / dd / yy):
Product Description
* Model No. or Product Name :
Product Serial Number : Serial Number(s) of Accessory (ies):
Installation Date: Total Copy Meter :
Date of last service maintenance :
List damaged and affected part(s) of the machine by description and part number :
*
Description Part Number
* Location of product and affected part(s):
Customer Identification
* Customer Name: * Name of Customer Contact Person :
*Address: E-mail: * Telephone :
Fax :
Customer Service Engineer Identification
* Name
(required for Xerox serviced equipment)
: Employee : E-mail :
Location : * Phone
(required for Xerox serviced equipment)
:
Individual Providing Notification
* Name :
* Title : * Telephone Number
:
* Organization : E-Mail:
Mailing Address :
*
Date Report Submitted :
* Required information is preceeded by asterisk, title shown in red , turquoise wash background