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No.

Date YYYY/MM/DD
CUSTOMER EXPERIENCE REPORT 3
TO : NIPRO HQS TO : 1 Prepared by

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Approved by

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TITLE

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CATEGORY* Complaint Repair Others:
SALES OFFICE /
COUNTRY
DISTRIBUTOR
HOSPITAL NAME

7 8
Ref. Installation Report Number of installed machines

9 A/B: Front Pipe A: Front Pipe, B: Powder A: Central, B: Powder

SUPPLY OF
CONCENTRATE A/B: Central A: Central, B: Front Pipe Others:

MACHINE INFORMATION
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MODEL TYPE INSTALLATION DATE YYYY/MM/DD
SERIAL NUMBER OCCURRENCE DATE YYYY/MM/DD
SOFTWARE VER. RUNNING HOUR(S) Hour(s)
Count of shifts/ sessions /cools Periodical inspection YES NO

PARTS INFORMATION (Please tick on the appropriate item.)

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FAILURE PARTS NAME (Lot/N, Ser/N) Nipro 12 13
Qty. RETURN SHIPMENT* REPLACEMENT PARTS*
(Please add more columns if necessary.) order code
Possible Necessary Qty:
Returned by: Delivered by :
Not Unnecessary
Reason: Already received on:
Possible Necessary Qty:
Returned by: Delivered by :
Not Unnecessary
Reason: Already received on:
Possible Necessary Qty:
Returned by: Delivered by :
Not Unnecessary
Reason: Already received on:
Possible Necessary Qty:
Returned by: Delivered by :
Not Unnecessary
Reason: Already received on:
To:
14 Attention:
DELIVERY ADDRESS To
Address:
Phone No.:

DETAIL INFORMATION
ERROR CODE* Error code observed 13Error No. No Error Code observed
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CONDITION(S) ERROR Rinse* Preparation Treatment
DETECTED.* Retrans Stand by Others:
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Chemical for Surface* Sodium hypochlorite Peracetic acid Others:
Name of chemical Original conc. Diluted conc. Temperature setting
1. % % °C
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Chemical for Sodium hypochlorite Peracetic acid Acetic acid
Hydraulics* Citric acid Hot Citric acid Others:
Name of chemical Original conc. Diluted conc. Temperature setting
1. % % °C
2. % % °C

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Cleaning program

Between treatment :
20 End of the day:
Cleaning pattern
Mon Tue. Wed. Thu.
Fri. Sat. Sun.

TROUBLE DETAILS AND TROUBLE SHOOTING

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BASIC INFORMATION
Influence to patients Non Slight Serious
Did the alarm sound? Yes No
Light indicator state R Y G B
Frequency State in the same model
Reproducibility after the alarm reset Yes No
Reproducibility after the power OFF-ON Yes No
Has the battery low alarm occurred? Yes No
1. Trouble details (including occurrence interval and frequency etc. of error) If needed, add more space.

Q. Did this trouble occur for the first time to this machine?* Yes No
If no, please inform CER No. for the last times. :
2. Trouble shooting actions If needed, add more space.

3. Current condition

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PLEASE ATTACH ANY PHOTO HERE OR FROM NEXT PAGE IF YOU HAVE. (History, Pressure graph etc.)

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QUALITY REPORT (This column will be filled by the factory after the investigation.)
QUALITY REPORT NO. Please refer to No.
ANY COMMENT
Rev. 2015.12.01

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