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Staff – Faculty
Equipment Loss / Damage Report
Revised 12/2012
Rockdale ISD
Technology Dept.
1. Staff/Faculty Member: _________________________________________
2. Date of Loss/Damage:_________________________ RISD#_______________________
3. Place Loss/Damage Occurred (circle one):
Classroom Lunchroom Gym Home Other:________________________
(please specify)
4. Individual(s) involved:
______________________________ ______________________________
______________________________ ______________________________
5. Briefly describe the loss/damage and the circumstances surrounding it:
___Accidental ___On Purpose
(Use the back for additional comments if needed.)
6. Staff / Faculty Comments:
7. Signatures:
______________________________ ______________________________
Principal Teacher
Please send this form directly to Technology Dept. after signature of Principal and Teacher.