Student Name
School
Student ID#
Date
 /
Month
 /
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Computer Tag Number:
Computer Case - top
Crack in case
Broken case
Hole in case
Computer Case - Bottom
Crack in case
Broken Case
Hole in Case
External Charger
Missing
End of cord broken
Computer screen - glass
Cracks in glass
Broken glass
Trackpad cracked Functional (computer turns on) Computer boots up
Keys missing
Trackpad cracked
Functional (computer turns on)
Computer boots up
Windows screen is visible
Damage Comments
Student Signature
Verifier Signature
Initials
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