Maintenance Request Form

Reporter Details

Date of Report:

MM

DD

YYYY

Time Problem Was Noticed:

Hour

Minute

Second

Teacher’s Name:

Classroom:

Contact Info:

Issue Details

Item/Area with Problem:

Description of Problem:

Urgency (High/Medium/Low):

Maintenance Team Action

Assigned To:

Action Taken/Repairs Made:

Date Completed:

MM

DD

YYYY

Follow-Up Needed?

Name/Signature of Maintenance Staff: