Discovery Date: Bar Code Number: _______ Quantity: ____________
Person Discovering the Loss: ____________________________________________________________
Description: ________________________________________________________________________ ____________________________________________________________________________________
Building: ___________________________________________ Building Code: ___________________
Department/Room: ___________________________ Controlling Person: ________________________
Reported as: ____Arson ____Theft ____Unexplained Loss
____Burglary ____Vandalism ____Failure to Return
Explain Circumstances Surrounding Loss: __________________________________________________ ____________________________________________________________________________________
Estimated Loss: $__________________________
Sent for Repair: ____Yes ____No Date Submitted for Repair: _______ Returned from Repair:_______
Police Report Filed: ____Yes ____No Police Report Date: __________ Police Report No._________
Insurance Report Filed: ____Yes ____No Insurance Report Date: _____________________________
Completed by: __________________________________________
(Initials) (date)
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Authorization:
Entered into the Fixed Assets Management System Record by: __________________________________
(Initials) (date)
The upper portion of this form is to be completed in accordance with the Fixed Assets Management System Administrative Regulations. The lower portion of this form is to be completed by the superintendent.
