Intake Report Form Form
Intake Report Form Form
Intake Information
Brought in by:_______________________ Date:______________________
Time:_______________
Received by:________________________ Phone:______________________
Description of Equipment:________________________________________
Tag Number:___________________ Serial Number:____________________
Description of Problem:_________________________________________________________
_________________________________________________________________
Analysis
Problem as Initially Determined:_____________________________________________________
________________________________________________________________
________________________________________________________________
Proposed Solution:_______________________________________________________
________________________________________________________________
Returned to Customer
Notified to be Picked Up by:_______________ Date:________________ Time:_______________
Picked Up by: ___________________
Date:________________ Time:_______________