Agency Property Damage Report

Agency Property Damage Report
HR-15: For any Damage to Siffrin Property and/or vehicles, staff must fill out an Agency Property Damage Report and turn it into the CFO within 24 hours of the incident that occurred. All Siffrin Property Damage Reports will be reviewed/ signed and dated by the Manager of the Program Involved.

If the property damage was the result of actions by an individual receiving services from Siffrin, or if the property damage can be defined as a major unusual incident, use the “Unusual Incident Report” form.
List Specific Vehicle or Part of Property that was Damaged*
Supervised LivingDay ServicesCSSESSTransportation
Your Supervisor*
If Other, enter their name here.
Email
example@example.com
Site of Incident*
Date of Incident*
Time of Incident*

:HourMinutesAM/PM Option
Name of Staff Involved*

First NameLast Name
Incident Description*
YesNo
Name of Witness*
If more than one witness, please list all.
Witness's description of the incident.*
Please list all details as desecribed by the witness named above.
Any Additional Information that may be helpful
Signature of Staff*
Staff Title*
(example: Direct Support Professional, Manager of Supervised Living)
MonthDayYear
DateHourMinutesAM/PM Option
Continue Code
Supervisor Signature*
Date

MonthDayYear
DateHourMinutesAM/PM Option
CFO Signature

_________________________________ Date __________ Time __________

Director of HR Signature (if applicable)

_________________________________ Date __________ Time __________

CEO Signature (if applicable)

_________________________________ Date __________ Time __________
Should be Empty: