Form RMP-001 "Report of Loss or Damage to State Property" - Hawaii

What Is Form RMP-001?

This is a legal form that was released by the Hawaii Department of Accounting & General Services - a government authority operating within Hawaii. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2014;
  • The latest edition provided by the Hawaii Department of Accounting & General Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form RMP-001 by clicking the link below or browse more documents and templates provided by the Hawaii Department of Accounting & General Services.

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Download Form RMP-001 "Report of Loss or Damage to State Property" - Hawaii

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PRINT LEGIBLY OR TYPE
STATE OF HAWAII
REPORT OF LOSS OR DAMAGE TO STATE PROPERTY
DEPARTMENT: _________________________________ UNIT/SCHOOL: ______________________________
DIVISION: _____________________________________ I SLAND: ______________________________
1. TYPE OF LOSS: Theft Burglary-Entry
Cash Loss Vandalism Fire/Arson
Storm Water Damage
Other
________________________
If "Other", Specify:
2. DATE INCIDENT DISCOVERED: _____________________ TIME: ___________ AM
PM
3. DATE INCIDENT OCCURRED: _____________________ TIME: ___________ AM
PM
4. DESCRIBE WHAT OCCURRED:
5. HOW WAS LOSS DISCOVERED?
6. WHO DISCOVERED LOSS? ____________________________________ TITLE________________________
PHONE #: ____________________________ EMAIL: ___________________________________________
7. WHO IS RESPONSIBLE FOR PROPERTY? _________________________ TITLE ________________________
PHONE #: ____________________________ EMAIL: ___________________________________________
8. ANY OTHER PERTINENT INFORMATION?
9. COMPLETE IF A CRIME IS SUSPECTED:
FORCED ENTRY? YES
NO
A. WHERE ENTRY MADE: ____________________________ MANNER: ______________________________________
. (Building & room number) (Window/door/louvre/etc.)
B. SECURITY: ________________________________ SECURITY RPT #: ______________________________________
.
(Fire/burglar/patrol/etc.)
C. POLICE OR FIRE REPORT? YES
NO
IF YES, #: _________________ DATE COMPLETED: _____________
D. ARE THERE ANY SUSPECTS? YES
NO
IF YES, PROVIDE INFORMATION ON SUSPECTS, IF KNOWN:
10. ESTIMATED AMOUNT OF THE LOSS: $ ________________
11. GENERAL DESRIPTION OF THE LOST OR DAMAGE PROPERTY
(Example: Dell laptop, mouse, power cord)
12. BUILDING & ROOM NO. WHERE PROPERTY WAS LOCATED:
Original to: DAGS/Risk Management
Form RMP-001 (08/14) Page 1 of 2
PRINT LEGIBLY OR TYPE
STATE OF HAWAII
REPORT OF LOSS OR DAMAGE TO STATE PROPERTY
DEPARTMENT: _________________________________ UNIT/SCHOOL: ______________________________
DIVISION: _____________________________________ I SLAND: ______________________________
1. TYPE OF LOSS: Theft Burglary-Entry
Cash Loss Vandalism Fire/Arson
Storm Water Damage
Other
________________________
If "Other", Specify:
2. DATE INCIDENT DISCOVERED: _____________________ TIME: ___________ AM
PM
3. DATE INCIDENT OCCURRED: _____________________ TIME: ___________ AM
PM
4. DESCRIBE WHAT OCCURRED:
5. HOW WAS LOSS DISCOVERED?
6. WHO DISCOVERED LOSS? ____________________________________ TITLE________________________
PHONE #: ____________________________ EMAIL: ___________________________________________
7. WHO IS RESPONSIBLE FOR PROPERTY? _________________________ TITLE ________________________
PHONE #: ____________________________ EMAIL: ___________________________________________
8. ANY OTHER PERTINENT INFORMATION?
9. COMPLETE IF A CRIME IS SUSPECTED:
FORCED ENTRY? YES
NO
A. WHERE ENTRY MADE: ____________________________ MANNER: ______________________________________
. (Building & room number) (Window/door/louvre/etc.)
B. SECURITY: ________________________________ SECURITY RPT #: ______________________________________
.
(Fire/burglar/patrol/etc.)
C. POLICE OR FIRE REPORT? YES
NO
IF YES, #: _________________ DATE COMPLETED: _____________
D. ARE THERE ANY SUSPECTS? YES
NO
IF YES, PROVIDE INFORMATION ON SUSPECTS, IF KNOWN:
10. ESTIMATED AMOUNT OF THE LOSS: $ ________________
11. GENERAL DESRIPTION OF THE LOST OR DAMAGE PROPERTY
(Example: Dell laptop, mouse, power cord)
12. BUILDING & ROOM NO. WHERE PROPERTY WAS LOCATED:
Original to: DAGS/Risk Management
Form RMP-001 (08/14) Page 1 of 2
PROPERTY REPORT
WHAT ACT, FAILURE TO ACT OR CONDITION(S) CONTRIBUTED MOST DIRECTLY TO THE LOSS?
(Example: This was a theft from a car. Employees should not leave valuables in clear view in an unattended vehicle)
WHAT ARE THE BASIC REASONS FOR THE ACT/FAILURE OR CONDITION?
WHAT ACTION HAS OR WILL BE TAKEN TO PREVENT RECURRENCE? LIST ALL ACTIONS IN ORDER.
1.
2.
3.
4.
GIVE DATE OF WHEN EACH ACTION WAS OR WILL BE COMPLETED:
1. _______________ 2. ______________ 3. _______________ 4. _______________
LOSS SEVERITY POTENTIAL:
PROBABLE RECURRENCE RATE:
MAJOR SERIOUS
MINOR
FREQUENT OCCASIONAL
RARE
ATTACH A COPY OF THE DETAIL INVENTORY OF PROPERTY REPORT OR OTHER DOCUMENTS AND INDICATE THE ITEMS
THAT ARE INVOLVED IN THE LOSS. IN ADDITION, INDICATE NEXT TO EACH ITEM THE BUILDING AND ROOM NUMBER
WHERE THE PROPERTY WAS LOCATED, IF APPLICABLE. NOTE: THIS DOCUMENTATION IS REQUIRED IN ORDER TO
VERIFY THE EXISTENCE OF THE PROPERTY.
I CERTIFY THAT THE ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
______________________________
_________________
___________________________
Supervisor Signature
Date
Name
_______________
________________________
______________________________
Work Phone
Job Title
Email
REVIEWED BY: __________________________________ EMAIL: __________________________________
(Risk Management Coordinator)
DATE: ___________________
PHONE: _____________________
Original to: DAGS/Risk Management
Form RMP-001 (08/14) Page 2 of 2
Original to: DAGS/Risk Management
Form RMP-001 (08/14) Page 2 of 2
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