Form EH&S-700 Rev 2.0 (21 February 2008) 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:
*Telephone:
*Address:
E-mail:
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
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