HCHS ONLINE FACILITIES and MAINTENANCE WORK ORDER FORM Instructions: Please fill out all of the fields on the form below. If this work order is in regards to a piece of equipment, It is important that you put the G number or Serial number. You will be contacted soon after submission.

PART I: CONTACT INFORMATION

Helix Staff Member Name (your first and last name) Your E-mail Address ex., jschmoe@helixcharter.net Helix Voicemail/Extension Date of request (please use xxxx/xx/xx form... ex, 2001/02/20)

PART II: DESCRIPTION OF MAINTENANCE SERVICE REQUEST

Type of Service: (choose one) Routine Safety Aesthetic Room Number: Vandalism? yes no If aesthetic, please provide source of funding: Description of services requested (please be specific):

PART III: EQUIPMENT SERVICE REQUEST

Inventory/G# and/or Serial# Description of Equipment (brand/model number/type of equipment) Location of Equipment (room # and location in room) Description of Services to be completed

PART IV: ADDITIONAL COMMENTS

Please write any additional comments that you would like to include with this form.