Change and Problem Report

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This is the standard form for instituting a change or reporting a problem at CIES Inc

First Name *

Please Enter Your First Name

Last name *

Please Enter Your Last Name

Department or Area of Concern *

Enter your Department or Area of Concern

Administration

Quality

Engineering

Purchasing

Shipping

Production

Airborne Electronic Hardware

Severity of Change or Problem *

If a customer reports a fuel leakage - Severity is Safety of Flight

Safety of Flight - There is an immediate issue with and aircraft or personal safety i.e. Fuel Leakage

Immediate or Significant - There is an issue that needs to be addressed that has an impact on improving safety or productivity

Normal Change or Enhancement

Required

Product

Fuel Level Sender

Other:

Please Provide a Summary of the Change or Problem

Safety of Flight - Aircraft Details

If Safety of Flight issue - Get as much information about the aircraft involved - Phone Numbers - Aircraft Type - N Number - Serial # - Location - Repair Station & Contact

Root Cause

If there is a preliminary idea of the Root Cause - Please include it here

Supervisor

Scott Philiben

Christine Sandsness

Andy Fackrell

Clear selection

Date Response Required *

YYYY

Submit

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