MSC 0050 Employee Assigned Property Tracking Form



Employee assigned property tracking

Employee name:       OR number:      

Program/position title:       Worksite location:      

|Item |Description or Serial/ID number |Received date |Return/ |

| | | |loss date |

|Calculator/Adding machine |      |      |      |

|Cases, bags, backpacks, etc. |      |      |      |

|Cell phone (iPhone) |      |      |      |

|Computer/Laptop/tablet |      |      |      |

|Computer accessories |      |      |      |

|(cables, power cords, flash/zip drives etc.) | | | |

|Credit cards (SPOTS, travel, phone, etc) |      |      |      |

|Duress cord & PMT, whistle |      |      |      |

|Keys for worksite/facility/files |      |      |      |

|ID badge/access or keycard |      |      |      |

|Label maker |      |      |      |

|Motor Pool card |      |      |      |

|Office furnishings and bulk supplies |      |      |      |

|Pager |      |      |      |

|Photo equipment - cameras, supplies |      |      |      |

|Printer |      |      |      |

|Projectors and presentation equipment |      |      |      |

|Recording equipment, camcorders, etc |      |      |      |

|TV monitor/DVD player |      |      |      |

|Other |      |      |      |

|Other |      |      |      |

|Other |      |      |      |

I understand the above described property is property of the Department of Human Services and/or the Oregon Health Authority, and of the specific program area in which I will be working. I agree that it will be used in compliance with all applicable policies of the department, and that I will exercise good care and stewardship while it is in my possession. If property is lost, damaged, transferred to another employee, or returned, I will notify my manager immediately so this form can be kept updated and the property can be effectively tracked and accounted for. I will return all assigned property upon termination of employment with the agency, or transfer to a different position or program area.

Employee printed name       Signature Date      

Manager printed name       Signature Date      

Review dates (form should be reviewed by manager and employee at least annually, and updated as needed):

Dates                                   Employee initials                                   Manager initials                                   

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