EquipmentDamageLossTheftReportForm.doc

Equipment Damage / Loss / Theft Report Form (Company Name) employees are required to report any damage, loss or theft of (Company Name) owned and operated equipment as soon as possible and submit a completed copy of this form within (XXXX) hours of the incident. Please note that where an injury occurs as a result of any damage, loss or theft of (Company Name) owned and operated equipment, employees are required to report the incident immediately, and submit a completed Incident Report and Investigation Form. Damage / Loss / Theft - Reported By Employee Name: Employee Number: Position/Title: Department: Company Phone: Company Email: Incident Information Incident Date (dd/mm/yy): ___/___/___ Time of Incident (24 hour clock): Reported on: ___/___/___ Time Reported (24 hour clock): Supervisor: Job Site: Specific Location: Equipment Information List of Equipment Damaged / Lost / Stolen (Please Specify) Equipment Identification Number(s) Equipment Location at Time of Damage / Loss How Was the Equipment Damaged / Lost / Stolen? (Complete Description) Description of Damage to Equipment Estimated Cost of Repair / Replacement Person Responsible for Equipment Was the Equipment Damage / Loss / Theft reported to the Police? Yes No If yes, please provide: Police Report Information Police File #: Officer In Charge: Station #: Phone #: Email: A Police Report (if Theft) and replacement cost invoice must be attached. Acknowledgement Agreement Supervisor: ____________________________________________ Signature: ____________________________________________ Date: ____________________________________________ 1.4