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General Information
TYPE OF INJECTOR * 
EUI HEUI CRI
NAME * 
  
First Last
COMPANY NAME
PHONE *  
(###) ###-####
ADDRESS
Street Address  
Address Line 2  
City State / Province / Region
Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegowina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia (Local Name: Hrvatska) Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard And Mc Donald Islands Holy See (Vatican City State) Honduras Hong Kong Hungary Icel And India Indonesia Iran (Islamic Republic Of) Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, Dem People'S Republic Korea, Republic Of Kuwait Kyrgyzstan Lao People'S Dem Republic Latvia Lebanon Lesotho Liberia Libyan Arab Jamahiriya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia, Federated States Moldova, Republic Of Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Ant Illes New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint K Itts And Nevis Saint Lucia Saint Vincent, The Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia (Slovak Republic) Slovenia Solomon Islands Somalia South Africa South Georgia , S Sandwich Is. Spain Sri Lanka St. Helena St. Pierre And Miquelon Sudan Suriname Svalbard, Jan Mayen Islands Sw Aziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic Of Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Is. Uruguay Uzbekistan Vanuatu Venezuela Viet Nam Virgin Islands (British) Virgin Islands (U.S.) Wallis And Futuna Islands Western Sahara Yemen Yugoslavia Zaire Zambia Zimbabwe
Postal / Zip Code Country
Automobile Information
YEAR *
MAKE *
MODEL *
NUMBER OF CYLINDERS *
2 3 4 5 6 8 10 12
TAG#
VIN #
Repair Information
DATE OF REPAIR

MM/DD/YYYY
COMPLAINT *
DIAGNOSIS *
CORRECTION *
Did you replace or repair the component?
Replace Repair
TO BE ANSWERED IF YOU REPLACED THE COMPONENT
IF YOU REPLACED THE COMPONENT, DID YOU CONSIDER REPAIRING IT?
Yes No
IF YOU DID CONSIDER REPAIRING THE COMPONENT, WHY DID YOU DECIDE NOT TO DO SO?
IF YOU DID NOT CONSIDER REPAIRING THE COMPONENT, WHY NOT?
DID THE NEED TO HAVE ADEQUATE INTERNAL CALIBRATION DATA (ICD) AGAINST WHICH TO TEST A REPAIRED COMPONENT PLAY ANY PART IN YOUR DECISION TO REPLACE THE COMPONENT RATHER THAN REPAIR IT?
Yes No
WOULD THE COST OF THE SERVICE TO THE CUSTOMER BEEN LESS IF YOU COULD HAVE REPAIRED THE COMPONENT INSTEAD OF REPLACING IT?
Yes No
IF SO, APPROXIMATELY WHAT WOULD THE DIFFERENCE IN COST HAVE BEEN? (PER COMPONENT)
$10-$20 $20-$30 $30-$40 $40-$50 > $50
TO BE ANSWERED IF YOU REPAIRED THE COMPONENT
IF YOU REPAIRED THE COMPONENT, DID YOU TEST AND VERIFY ITS OPERATION AGAINST INTERNAL CALIBRATION DATA (ICD) AFTER THE REPAIR WAS COMPLETED?
Yes No
IF SO, WHERE DID YOU GET THE ICD AGAINST WHICH YOU TESTED IT?
IF YOU USED OEM SPECIFIED ICD, HOW DID YOU OBTAIN IT?
IF YOU DID NOT USE OEM SPECIFIED ICD, WHY NOT?
IF YOU DID NOT USE OEM SPECIFIED ICD, WAS IT AVAILABLE FOR YOU TO USE?
Yes No
IF YOU DID NOT USE OEM SPECIFIED ICD, DID YOU THEN OR HAD YOU PREVIOUSLY MADE ANY EFFORTS TO OBTAIN IT?
Yes No
IF SO, WHAT EFFORTS WERE MADE AND WHAT WERE THE RESULTS?
WERE THE VEHICLE'S EMISSIONS TESTED AFTER THE REPAIR?
Yes No
IF SO, WERE THE EMISSIONS HIGHER, LOWER OR ABOUT THE SAME AS THE EPA PRESCRIBED EMISSIONS LIMITS FOR THAT VEHICLE?
Higher Lower About the same
IF THE EMISSIONS WERE HIGHER, DO YOU HAVE AN OPINION AS TO WHY THEY WERE HIGHER?
IF YOU DID NOT USE OEM SPECIFIED ICD AND THE EMISSIONS WERE HIGHER, IN YOUR OPINION, WOULD TESTING AND VERIFYING AGAINST OEM SPECIFIED ICD HAVE MADE A DIFFERENCE IN THE EMISSIONS?
Yes No
IF THE EMISSIONS WERE LOWER, DO YOU HAVE AN OPINION AS TO WHY THEY WERE LOWER?
TO BE ANSWERED BY ALL
IF YOU DO NOT PRESENTLY HAVE ACCESS TO OEM SPECIFIED ICD, WOULD YOU USE IT IF YOU COULD GET ACCESS TO IT? * 
Yes No