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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.
FC-L1 Flow Calibrator Problem Report Form
If a problem occurs, please copy and fill out this Problem Report Form and contact your
Sibata representative or the distributor where you purchased the product.
Date completed:
(yyyy/ mm/dd)
Circumstances Under Which the Product is Used
Model: FC-L1
Purchase date:
(yyyy/ mm/dd)
Serial No.:
Software version:
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:
Model number of connected low volume pump or PM2.5 sampler:
Problem Description
Frequency of occurrence:
: Daily
: Occasionally
: Rarely
: Other
(For "Other," explain:
)
Timing of occurrence:
: Immediately after purchase
: Within 1 month
: Within 1 week
: Other (
)
Symptoms (in as much detail and as specifically as possible):
Example: No flowrate is displayed, even when the pump is pumping air through the unit.
Check List
(circle all applicable)
Is anything displayed on the screen when the unit is switched ON? (Yes / No)
Is the unit rusty, corroded, or dirty? (Yes / Not very much)
Is the unit being used in an environment containing significant levels of chemicals?
(Yes / No)
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.
