Research Corporation of the University of Hawaiʻi

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STATE OF HAWAII
REPORT OF LOSS OR DAMAGE TO STATE PROPERTY
DEPARTMENT: _________________________________ UNIT/SCHOOL: ______________________________
DIVISION: _____________________________________
1. TYPE OF LOSS: Theft Burglary-Entry Cash Loss
Storm Water Damage Other
2. DATE INCIDENT DISCOVERED: _____________________ 3. DATE INCIDENT OCCURRED: _____________________ 4. DESCRIBE WHAT OCCURRED:
5. HOW WAS LOSS DISCOVERED?
ISLAND: ______________________________ Vandalism Fire/Arson
If “Other”, Specify: ________________________ TIME: ___________ AM PM
TIME: ___________ AM PM
6. WHO DISCOVERED LOSS? ____________________________________ TITLE________________________ PHONE #: ____________________________ EMAIL: ___________________________________________
7. WHO IS RESPONSIBLE FOR PROPERTY? _________________________ TITLE ________________________ PHONE #: ____________________________ EMAIL: ___________________________________________
8. ANY OTHER PERTINENT INFORMATION?
9. COMPLETE IF A CRIME IS SUSPECTED: FORCED ENTRY? YES NO
A. WHERE ENTRY MADE: ____________________________ MANNER: ______________________________________ . (Building & room number) (Window/door/louvre/etc.)
B. SECURITY: ________________________________ SECURITY RPT #: ______________________________________ . (Fire/burglar/patrol/etc.)
C. POLICE OR FIRE REPORT? YES NO IF YES, #: _________________ DATE COMPLETED: _____________ D. ARE THERE ANY SUSPECTS? YES NO IF YES, PROVIDE INFORMATION ON SUSPECTS, IF KNOWN:
10. ESTIMATED AMOUNT OF THE LOSS: $ ________________
11. GENERAL DESRIPTION OF THE LOST OR DAMAGE PROPERTY (Example: Dell laptop, mouse, power cord)
12. BUILDING & ROOM NO. WHERE PROPERTY WAS LOCATED:
Original to: DAGS/Risk Management Form RMP-001 (08/14) Page 1 of 2
PROPERTY REPORT
WHAT ACT, FAILURE TO ACT OR CONDITION(S) CONTRIBUTED MOST DIRECTLY TO THE LOSS? (Example: This was a theft from a car. Employees should not leave valuables in clear view in an unattended vehicle)
WHAT ARE THE BASIC REASONS FOR THE ACT/FAILURE OR CONDITION?
WHAT ACTION HAS OR WILL BE TAKEN TO PREVENT RECURRENCE? LIST ALL ACTIONS IN ORDER. 1.
2.
3.
4.
GIVE DATE OF WHEN EACH ACTION WAS OR WILL BE COMPLETED:
1. _______________ 2. ______________ 3. _______________ 4. _______________
LOSS SEVERITY POTENTIAL: PROBABLE RECURRENCE RATE:
MAJOR SERIOUS MINOR FREQUENT OCCASIONAL RARE
ATTACH A COPY OF THE DETAIL INVENTORY OF PROPERTY REPORT OR OTHER DOCUMENTS AND INDICATE THE ITEMS THAT ARE INVOLVED IN THE LOSS. IN ADDITION, INDICATE NEXT TO EACH ITEM THE BUILDING AND ROOM NUMBER WHERE THE PROPERTY WAS LOCATED, IF APPLICABLE. NOTE: THIS DOCUMENTATION IS REQUIRED IN ORDER TO VERIFY THE EXISTENCE OF THE PROPERTY.
I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
______________________________
Supervisor Signature
______________________________
Job Title
___________________________
Name ________________________
Email
_________________
Date _______________
Work Phone
REVIEWED BY: __________________________________ EMAIL: __________________________________ (Risk Management Coordinator)
PHONE: _____________________
DATE: ___________________
Original to: DAGS/Risk Management
Form RMP-001 (08/14) Page 2 of 2
Original to: DAGS/Risk Management
Form RMP-001 (08/14) Page 2 of 2
PREVENTION ANALAYSIS