Tennessee



|[pic] |Tennessee Department of Children’s Services |

| |Incident Report for Damaged, Missing, Lost or Stolen State Property and Equipment |

|Employee/Reporter’s Name:       |Employee EI#:       |Employee Phone:       |

|Date/Time Incident Occurred or Item Discovered Missing: |Date/Time Reported:       |

|     /     /      |     :      a.m./ p.m. |     /     /      |     :      a.m./ p.m. |

|Office/Facility Name:       |Address:       |

|Provide an explanation of events that caused the damaged, missing, lost or stolen state property and equipment: |

|      |

Check property/equipment that is reported damaged, missing, lost, or stolen below:

| |Damaged |Missing |Lost |Stolen |Replacement |

| | | | | |Yes |No |

|Camera | | | | | | |

|Serial Number (if known):       | | | | | | |

|State Tag Number (if known)       | | | | | | |

|Credit Card/Gas Card* | | | | | | |

|Numbers (if known):       | | | | | | |

|*Note: if Credit card, contact Fiscal immediately.  If Gas card, contact Central Office | | | | | | |

|Transportation Coordinator immediately. | | | | | | |

|WeCar Card | | | | | | |

|Keys | | | | | | |

|Computer | | | | | | |

|Serial Number (if known):       | | | | | | |

|State Tag Number (if known)       | | | | | | |

|Type/Description: Laptop Desktop Tablet Dock | | | | | | |

|Printer | | | | | | |

|Serial Number (if known):       | | | | | | |

|State Tag Number (if known)       | | | | | | |

|Radio | | | | | | |

|Other:       | | | | | | |

|Serial Number (if known):       | | | | | | |

|State Tag Number (if known)       | | | | | | |

|Employee/Reporter’s Signature | |Date | |Supervisor’s Signature | |Date |

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