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Job title

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Product information

Product type

Product

Part number (PNR)*

Serial number (SER)

Unknown serial number?

Serial number unknown

Ex product:

Yes
No

SIL product:*

Yes
No

Meggitt SA purchase order number:

Date of purchase:

Product under warranty

Yes
No
Warranty status unknown

Site where installed:

End user:

Return information

Reason for return*

Type of problem

How long was the operating time before failure?

Description of failure:

Additional information:

Note: Please provide as much information as possible, in order to help with problem diagnosis.

Ex product information (additional information required for Ex products only)

Is the product installed in a hazardous area (potentially explosive atmosphere)?

Yes
No

Additional information:

SIL product information (additional information required for SIL products only)

Is the product installed in a safety-related system?*

Yes
No

In the safety-related system, did the system fail** in a safe mode? (That is, the safety relay operated but the trip was spurious.)*

Yes
No
Not applicable

** A faulty indicator LED is considered as a cosmetic failure.

In the safety-related system, did the system fail** in a dangerous state? (That is, the failure did not result in the safe state.)*

Yes
No
Not applicable

** A faulty indicator LED is considered as a cosmetic failure.

Additional information:

Note: For SIL products used in functional safety contexts/systems, the SIL product information section must be completed.

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Energy product return form

Contact information

Product information

Return information

Ex product information (additional information required for Ex products only)

SIL product information (additional information required for SIL products only)

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