For
Emergency/Urgent Maintenance Issues
please submit form then call your maintenance team member.
Avalon
Jim Strawser
407-920-7783
After hours
Alex Da Silva
941-706-8512
Program Property
*
Is this a client move request?
*
Yes
No
Is this a tour preparation request?
*
Yes
No
Is this a vehicle issue?
*
Yes
No
Priority
*
Type of Repair
*
Property Damage/Repair (walls, paint, railings, etc.)
Equipment Repair (appliances, toilets, sinks, etc.)
Replacement Request (bed, chair, tv, etc.)
System Maintenance (a/c, plumbing, lighting, etc.)
New Item Request
Other
Location of Repair
*
External Grounds
Building Exterior
Common Area
Living Room
Dining Area
Hallway
Kitchen
Bathroom
Laundry Room
Garage
Med Room
Therapy Area
Resident Room (# or Initials)
Description of Request/Work Order
*
Computer Submission: Please upload an image of damage or maintenance issue. DO NOT include any PBS, staff or any names or identifying images in picture.
Phone or Tablet Submission: Please upload an image of damage or maintenance issue. DO NOT include any PBS, staff or any names or identifying images in picture.
How was damage caused?
*
Client - Damage caused by Outburst/Behavior
Client - Accidental Damage
Employee - Damage caused by failure to follow directive/policy
Employee - Accidental Damage
General Maintenance/Normal wear and tear
Unknown
Other
If damage was caused by a Person (Client, Employee or Other), place their initials below (write NA if not a Person):
*
Date
/
Month
/
Day
Year
Date Accident or Behavior Occurred
Back
Next
Resident Move New Location (Program Director or Higher Approval Required)
Resident to be moved
First Name
Last Name
Move by Date
-
Month
-
Day
Year
Date
Tour Location
Date of Tour
/
Month
/
Day
Year
Date
Vehicle Number or Letter
Last 5 digits of VIN# or Designated Letter / #
License Plate
Vehicle Issue
Tires
Head or Brake Lights
Fuel
Maintenance
Body Damage
Windshield / Wipers
Other
Submitted by:
*
First Name
Last Name
Phone Number (Only used if clarification needed)
*
-
Area Code
Phone Number
Enter Email to Receive Confirmation of Submission
example@example.com
Submit
Should be Empty: