University of California, Irvine		
Property Damage/Loss Report

Date of incident: ___________________	Time:___________  Location: _________________________ 

Name: _____________________________________________ Phone #: (_____) ______-____________

Address:	_____________________________________________________________________________             _____________________________________________________________________________________

Describe the incident that caused the Damage/Loss:
__________________________________________________________________________________________________________________________________________________________________________ 

Describe what was damaged or destroyed:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
If needed, please use the back of this form to record additional information.

Details: 

Police responded?   Y    N          If so: Officer’s name: ___________________ badge #:  ___________ 
Officer’s department: ________________________________	Phone #: (_____) ______-____________
Case #_____________________  

Witness information:

Name:  ________________________________	Address: ______________________________________
Phone #: (_____) ______-____________             	______________________________________

Name:  ________________________________	Address: ______________________________________
Phone #: (_____) ______-____________             	______________________________________

UCI employee most familiar with incident: 

Name:  ________________________________   	Department: ___________________________________
Phone #: (_____) ______-____________             

Report completed by:

Name: ___________________________________	Title: ______________________________________
	(Please print)
Department: ___________________________________________	Phone #: (____) _____-__________             

Signature: _____________________________________________	Date completed: _______________