School/site Theft And Property Damage Report (616 Form)

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School/ Site Theft And Property Damage Report 
(616 Form) 
INSTRUCTIONS: This form is to assist you in reporting incidents of theft or damage that may occur at 
your school/site.  It is important to document all incidents as soon as they happen.  Please follow the 
instructions listed below and fill this form out completely and send to Risk Management WITHIN 72 
HOURS. 
Date 
School/Site 
Date of Occurrence 
Discovered By: 
Date Discovered 
DAMAGE (Check one) 
THEFT 
Criminal Damage 
TUSD Property Stolen 
Fire/Wind/ Rain 
Forced Entry / Burglary 
No Sign of Forced Entry 
________________ 
OTHER 
If the theft/damage occurred through forced entry or by a third party and you are claiming restitution, all of the 
following documents must be completed and sent to Risk Management to proceed with the claim. 
School Safety Incident Report 
Completed Theft and Damage Report (Form 616) 
Police Report 
Completed Requisition (without budget code) 
Has TUSD Security been 
When? 
TUSD Case Number? 
notified: 
Have Police been notified? 
When? 
Police case # 
LIST DAMAGES / STOLEN ITEMS HERE – USE ADDITIONAL PAPER IF NEEDED 
If Custodian or Engineer did cleanup in­house, please fill out the Custodian Work Order Form located on Risk Management Intranet Site/Forms. 
TELL WHAT HAPPENED IN YOUR OWN WORDS HERE:  (Use additional sheet of paper if more space is needed) 
_________ 
_____________________________________ 
Please Print Site Administrators Name Here 
Signature of Site Administrator 
Fax Form To Risk Management at 225­4869

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