Xerox WorkCentre 6605

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