Accurate location information is critical for rapid response. Please provide precise details to help our facilities team locate and address the issue efficiently. All fields marked as mandatory must be completed to prevent delays.
Full Name
Employee ID Number
Department or Business Unit
Information Technology
Human Resources
Finance & Accounting
Marketing & Communications
Operations
Legal & Compliance
Executive Management
Facilities Management
Other
Email Address
Phone Extension or Mobile Number
Building Name or Number
Floor Level
Basement Level 3
Basement Level 2
Basement Level 1
Ground Floor
Floor 1
Floor 2
Floor 3
Floor 4
Floor 5
Floor 6
Floor 7
Floor 8
Floor 9
Floor 10
Floor 11-20
Floor 21-30
Floor 31+
Zone or Section Code
Room Number or Office Identifier
Exact Location Details and Landmarks
Is this a recurring issue that has happened before?
Have you previously submitted a maintenance request for this same location or equipment?
Proper categorization helps route your request to the right specialist immediately. The severity rating enables priority triage to ensure critical issues receive emergency response. Please be objective and accurate in your assessment.
Primary Issue Category
Heating, Ventilation & Air Conditioning (HVAC)
Plumbing & Water Systems
Electrical & Power Systems
Door Access & Security Systems
Safety & Emergency Systems
Structural & Interior Fixtures
Other Issue Type
When was the issue first noticed?
Is the issue actively ongoing right now?
Severity Rating - Rate the operational impact level
Severity Rating Guide: 1 = Minor inconvenience (aesthetic, minimal disruption), 2 = Moderate disruption (affects comfort but work continues), 3 = Significant impact (notable productivity loss, multiple users affected), 4 = Major disruption (area unusable, critical systems compromised), 5 = Critical emergency (immediate safety risk, life safety systems failed, business continuity threatened)
Impact Assessment - Select all areas affected
Employee health and safety
Property or asset damage risk
Direct productivity loss
Client or customer service impact
Regulatory compliance concern
Data center or IT equipment
Meeting or event disruption
No significant impact beyond location
Estimated number of employees directly affected by this issue
Does this issue affect business-critical operations or systems?
Detailed descriptions and visual evidence significantly accelerate diagnosis and repair. Please be thorough in your explanation and upload multiple photos from different angles. Include any error messages, unusual sounds, odors, or behavioral patterns of the affected system.
Comprehensive Problem Description
Error Codes or Diagnostic Messages
Equipment or Asset Tag Number
Have you attempted any troubleshooting or corrective actions?
Is there visible damage to equipment, fixtures, or the building structure?
Upload Photographs of the Issue - Minimum 2 photos recommended
Upload Additional Photos from Different Angles or Context
Upload Supporting Documents - Equipment manuals, previous service reports, warranty information, or relevant correspondence
Does this present an immediate safety hazard to people in the vicinity?
Has the affected area been secured, barricaded, or marked with warning signs?
Additional Comments or Special Instructions
To ensure efficient repair work, we need to coordinate access timing and security requirements. Please specify when maintenance personnel can access the location and who will be available to grant entry. This information helps avoid delays and ensures compliance with security protocols.
Preferred Access Date
Preferred Access Time
Are there specific time restrictions or blackout periods?
Business hours only (8:00-18:00)
After hours permitted (18:00-22:00)
Weekend access OK
No time restrictions
Other specific restrictions
Who can grant physical access to the affected area?
Myself - I will meet the technician
Facilities Manager
Department Head
Security Operations Center
Reception Desk
Other designated person
Is a physical key or access card required to enter the area?
Are there security clearance or escort requirements for external vendors?
Will someone be present at the location during the repair work?
Special Access Instructions
Are there parking arrangements available for vendor vehicles?
Does the repair require equipment shutdown or power isolation?
Can the work area be left unlocked if no one is present?
This section is for Facilities Management team use to authorize work, assign vendors, and document dispatch decisions. Proper authorization ensures compliance, budget control, and quality assurance. All critical maintenance requires manager sign-off before external vendor dispatch.
Does this repair require external vendor support beyond internal facilities capabilities?
Internal Facilities Team Assessment Notes
Priority Assignment for Dispatch
Emergency - 2 Hour Response Required
Critical - Same Day Response
High - 24 Hour Response
Medium - 3 Business Day Response
Low - 5 Business Day Response
Scheduled Maintenance - Next Available Slot
Assign To
Internal Facilities Maintenance Team
External Vendor - HVAC Specialist
External Vendor - Licensed Plumber
External Vendor - Certified Electrician
External Vendor - General Contractor
External Vendor - Security Systems Technician
External Vendor - Fire Safety Systems
External Vendor - Other Trade
Facilities Manager Approval Signature
Vendor Dispatch Date and Time
Expected Completion Date
Approved Cost Estimate
Purchase Order Number
Vendor Primary Contact Details
Is a formal safety briefing or site induction required for external vendors?
I authorize the work to proceed based on the information provided, confirm budget availability, and accept responsibility for dispatch coordination