Xerox Phaser 3100MFP Service Manual page 241

EHS 700 - Health & Safety Incident Report Form for
Incidents Involving a Xerox Product
Details of Incident
*Description Of Incident: (Check all that apply)
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:
MANDATORY DESCRIPTION
contributed to the incident. Hardware involved in the incident should be preserved and retained for further
investigation should investigation be deemed necessary by EH&S.
LIST INCIDENT DESCRIPTIONS AND SUPPORT DIAGRAMS/DATA INCLUDED OR ATTACHED:
*Any damage to customer property?
*Did external emergency response provider(s) such as fire department, ambulance, etc. respond?
No Yes Identify:
Apparent cause of incident (identify part that is suspect to be responsible for the incident)
*Preliminary actions taken to mitigate
Instructions: E-mail or fax both pages of this completed form to EH&S:
•
For incidents in Xerox Europe and Developing Markets East
(Middle East, Africa, India, China, and Hong Kong)
Submit to Elaine Grange
e-mail:
•
For incidents in North America and Developing Markets West
(Brazil, Mexico, Latin America North and Latin America South,
Submit form to Doris Bush
e-mail:
* Required information is preceeded by asterisk,
Form EH&S-700 Rev 2.0 (21 February 2008)
(above): Provide a detailed description of all valid factors that may have
No Yes
(i.e., source, names of individuals)
incident:
ehs-europe@xerox.com
usa.xerox.ehs@xerox.com
title shown in
Describe:
or fax: +44 (0) 1707 35 3914 [Intelnet 8*668 3914]
or fax 888-845-0908 [1-585-422-7918 / Intelnet 8*222-7734]
red, turquoise wash background
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North America Letter Format