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Form EH&S-700 (27Mar2007)
Product Description
Model No. or Product name:
Product Serial : 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):
Individual Providing Notification
Name:
Title:
Telephone Number:
Organization:
E-Mail:
Mailing Address:
Date Report Submitted:
Instructions: E-mail or fax this completed form to EH&S:
For incidents in Xerox Europe and Developing Markets East
(Middle East, Africa, India, China, and Hong Kong)
please e-mail: Elaine.Grange@xerox.com
or fax: +44 (0) 1707 35 3914 [intelnet 8*668 3914]
Note: - If you fax this form, please also send original by internal mail
For incidents in North America and
Developing Markets West
(Brazil, Mexico, Latin American North and Latin American South)
please e-mail: Doris.Bush@xerox.com
or fax 585 422 6449 [Intelnet 8*222 6449]
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