Damaged Equipment Form-Griffin High
This form must be submitted after damaged equipment has been assessed by IT. You should receive an email from the Incident IQ ticketing system when the assessment ticket has been closed by IT. Use the information from the Staff Report Form and the IT Assessment Label on the device to complete the form.
SIG 1003(a), SIG 1003(g), Title I, or Title IV? *
Information on Item(s) from Inventory Log *
Please paste in the Item Name (Type of Equipment / Brand / Model Number), Vendor, Funding Source, Price, Purchase Date, PO#, and Serial Number of the damaged item(s).
How is the Item Damaged? *
Ex: Cracked screen, broken power socket, locked hinges etc.
Who Caused the Damage? *
Name of Person Who Caused the Damage. *
(If damage is caused by a student or staff member. Only if a product defect, list NA)
When Did the Damage Occur? *
MM
/
DD
/
YYYY
Time
:
Where Did the Damage Occur? *
(In which teacher's classroom, Media Center, off-campus, etc.)
List any Items That are Unable to be Repaired and WHY They Cannot be Repaired:
(Ex: Dell Optiplex 780 (GBVY32K) - Sustained lightning damage; internal components unable to be repaired)
If Applicable, What Specific Parts Will Fix the Device? (NA if device cannot be repaired) *
Ex: screen replacement, left hinge, right hinge, keyboard, individual key, touchpad, etc.
Where Will IT Fix the Item(s)? *
If Applicable, how Will Repair Parts be Obtained? (NA if device cannot be repaired) *
If Parts Must be Ordered, Include the Quote(s) for the Parts
Submitted by: *
First Name and Last Name
Submit
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