Xerox Phaser 3100MFP Service Manual page 240

For incidents in Canada:
PIPEDA consent given
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:
Installation Date:
Date of last service maintenance:
List damaged and affected part(s) of the machine by description and part number:
Description
*
*Location of product and affected part(s):
Customer Identification
*Customer Name:
*Address:
Customer Service Engineer Identification
*Name
(required for Xerox serviced equipment)
Location:
Individual Providing Notification
*Name:
*Organization:
Mailing Address:
* Required information is preceeded by asterisk,
Form EH&S-700 Rev 2.0 (21 February 2008)
EHS 700 - Health & Safety Incident Report Form
for Incidents Involving a Xerox Product
YES
E-mail:
: Employee:
*Phone
(required for Xerox serviced equipment)
*Title:
title shown in
EH&S Office Use ONLY
NO
EH&S Incident Reference Number:
Serial Number(s) of Accessory (ies):
Total Copy Meter:
*Name of Customer Contact Person:
*Telephone:
Fax:
*Telephone Number
E-Mail:
Date Report
*
red, turquoise wash background
Part Number
E-mail:
:
:
Submitted:
North America Letter Format