Safety and Risk Management, Auxiliary and Support Services, A Department of Finance and Administration, 34 Broad Street, Suite 120, Tel: 404-651-2170, Fax: 404-651-0350 Georgia State University Logo
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Departmental Forms


Property Damage Report Form


General Information

Department:

Employee Name:

Email Address:

Phone Number:

Fax Number:

 

Incident Information

 

Date of Incident:

Time of Incident:

AM

PM

 

Location of Incident:

Building:

Room:

 

Type of Loss:

Property Damage

Vandalism

Fire

Water Damage

Theft

Other: 

Incident Description

 

Description of How the Incident Occurred:

 

Description of Property Damage (List items with GSU Property No., Serial No., Model No.):

 

Witnesses Names and Addresses:

 

Cost (check ONE in each column below):

Estimate

Replacement Cost 

$ 

Invoice

Repair Cost 

$ 

 

Bills Being Sent to Safety and Risk Management? Yes No

 

** For Transient State Property Only:

Has the Transient State Property Form been submitted to Safety and Risk Management?

Yes No

 

 

Employee Filing This Report

 

Name of Employee Filing this Report: 

Phone Number: 

Date: 

 
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