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Form EH&S-700 (08Nov2000)
APPENDIX A: Health & Safety Incident Report Involving a Xerox Product
Customer Identification
Customer Name: Name of Customer Contact Person:
Telephone : Address: E-mail:
Fax :
Customer Service Engineer Identification
Name: Employee : Pager :
Location: Phone :
Details of Incident
Date Of Incident (mm / dd / yr):
Description Of Incident: (Check all that apply)
Excessive Smoke
Describe quantity and duration of smoke:
Fire with open flames seen
Electric shock to operator or service representative
Physical injury/illness to operator or service representative
Describe:
Other
Describe:
Any damage to customer property? No Yes Describe:
Did external emergency response provider(s) such as fire department, ambulance, and etc. respond?
No Yes Identify: (ie, source, names of individuals)
Apparent cause of incident (identify part that is suspect to be responsible for the incident)
Preliminary actions taken to mitigate incident:
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