This form is also known as the EDRM1. Your details Establishment name * Cost centre * Address * Contact name * Contact email address * Contact telephone number * Incident details Type of damage * Theft Vandalism Accidental damage Fire Storm or water Impact Date of incident/ Date of damage discovery * Day Day12345678910111213141516171819202122232425262728293031 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Year Year2019202020212022202320242025 Time of incident * Estimate of total cost of loss/repairs/replacement * Location of incident * Description of incident including details of damage * Were the police advised about the incident? * Yes No Name of Police Officer * Name of station * Crime reference number * Preventative measures implemented as a result of the incident Details of any preventative measures implemented as a result of the incident *