Touchless Water Fountain Maintenance Request Form
Submit this form to report issues and request maintenance for a touchless water fountain.
Your Full Name
*
First Name
Last Name
Your Email Address
*
example@example.com
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Fountain Location (Building, Floor, Area)
*
Type of Issue
*
No water dispensing
Low water pressure
Water temperature issue
Sensor not working
Leaking or dripping
Unusual noise
Other
Describe the Problem
*
Urgency Level
*
Low (minor inconvenience)
Medium (needs attention soon)
High (immediate attention required)
When did the issue start?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Is the fountain completely out of service or partially working?
*
Completely out of service
Partially working
Visible Symptoms (select all that apply)
No water flow
Continuous running
Leaking
Unusual odor
Strange noise
Other
Preferred Access Time for Maintenance
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Additional Notes
Submit Request
Should be Empty: