Damaged Uniform Replacement Form

Damaged Uniform Replacement Form
House uniform boots, pants, and shirts which are irreparably damaged during firefighting, medical responses, or department sponsored training activities, shall be replaced under the following conditions:
- Report that the item is irreparably damaged.
- Report that the damage occurred in the line of duty and circumstances leading to the damage.
- Report the approximate age of the damaged uniform (3 years old or less = 100% replacement cost covered by dept.)
- Document the immediate supervisor and their approval.
Damage must be reported during the same shift that damage occurred.
Your Name

First NameLast Name
Your Email
example@example.com
Supervisor's Email
example@example.com
Checking the box below indicates the supervisor has approved this request:

Approved
Which situation did damage occur to uniform items?*

Fire Call / Training relatedMedical Call relatedOther
Please list all items below. Be sure to include specific item damaged, size, and age of item*
If possible, add photos of damaged items:

Cancelof
Should be Empty: