1.   Is device out of service?   Yes      No

  2.   Has device been replaced with a back-up?    Yes      No

  3.   If yes where did the back up come from? 

  4.   Enter device name and origin:

  5.   Enter device model number:    Inventory ID:
  6.  What is wrong with the equipment? Please explain in detail.

   7. Can you recommend a repair solution?

   8. Your name and date: