equipment repair form

Please use this form to report broken or stolen equipment

Name

First Name

Last Name

Email address

Date issue was noticed:

MM

DD

YYYY

Equipment in need of repair/replacement:

(please describe eq, provide model # and serial #)

What caused the need for repair/replacement?

accidental damage

deliberate damage

natural wear and tear

Describe the problem in detail:

What course of action do you recommend?

repair

replace

dispose of but do not replace

Additional notes:

(please use this space to provide details about the repair including: who caused the issue, who noticed the issue and any additional recommendations regarding use privileges or needed procedures.