DAMAGED/LOST EQUIPMENT REPORT
Please fill out this form immediately following an incident involving MAL equipment. If there are multiple incidents please fill out a separate form for each.
Person Reporting (Person filling out form)
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First Name
Last Name
Person Reporting Phone Number
*
-
Area Code
Phone Number
Person Reporting Email
*
example@example.com
Date of Incident
Approximate Time of Incident
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1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Where was the item checked out from?
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Media Arts Checkout (HFAC)
FSSS Checkout (MPS)
What item(s) were damaged/lost? Please include barcode numbers so we know exactly which items were damaged/lost?
*
How was the item broken/lost? Please include detailed description, including: background information, description of event(s), location, and detailed description of damage sustained (if damaged).
*
Witnesses - Please list one to three witnesses and their contact information.
*
Person(s) Responsible
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Person(s) Responsible Phone
*
Person(s) Responsible Email
*
Class or Activity this project was for?
*
Example: TMA 185, Practice Exercise, Fiction Capstone, etc.
Activity Supervisor (Professor/Mentor)
*
First Name
Last Name
Activity Supervisor Email
*
example@example.com
Who was the Checkout Attendant who was present when you returned the items?
*
Submit
Should be Empty: