Asset Damage Incident Report

Date of incident: _________________________________________ Time of incident: ____________________

Location incident happened: __________________________________________________________________
Name of person with the asset: ________________________________________________________________
Department person works for: _________________________________ Supervisor: ______________________
What happened:
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Was anyone injured:
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What could have prevented this from happening:
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Asset that got damaged: ________________________________ Checked out to: ________________________
By signing below you are not admitting to any guilt or taking liability of the incident. By signing below you are
saying that all the information above is correct to the best of your knowledge. If you need more space please
use a separate sheet of paper.
Sign: ______________________________________________________ Date: __________________________

DO NOT WRITE ON THIS SIDE. TO BE FILLED OUT BY ADMINISTRATION ONLY

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Employee: ________________________________________ A Number: _______________________________
Prior incidents: _____________ Total cost for this incident: _________________________________________
Further Investigation: ___ YES ___ NO

Continued By: ____________________________________

Asset Condition: ______________________________ Will asset be REPLACED or REPAIRED: _______________

Location of the asset: ________________________________________________________________________
Further action to take place:
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Reports filed with this IR include:
__ IR __Pictures __Witness Statement(s) __ Follow up Investigation __Police Report __ Asset Condition Scale
Administration: ___________________________________________________ Date: ____________________
Department Supervisor: ____________________________________________ Date: ____________________
Director: _________________________________________________________ Date: ___________________