Xerox FaxCentre 2121 Service Manual page 225

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APPENDIX A: Health & Safety Incident Report Involving a Xerox Product
Customer Identification
Customer Name:
Address:
Customer Service Engineer Identification
Name:
Location:
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
Did external emergency response provider(s) such as fire department, ambulance, and etc. respond?
No Yes
Apparent cause of incident (identify part that is suspect to be responsible for the incident)
Preliminary actions taken to mitigate incident:
Form EH&S-700 (08Nov2000)
E-mail:
Employee :
Phone :
Identify: (ie, source, names of individuals)
Name of Customer Contact Person:
Telephone :
Fax :
Yes Describe:
Pager :
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