Nursing Home Repair Work Order Form

This form is designed to streamline the repair and maintenance request process within the nursing home facility, ensuring that issues are addressed promptly and efficiently. To fill out this form, provide facility and resident information, describe the issue, select the priority level, check the requested repair/maintenance, add any additional comments or instructions, and sign and date the form before submitting it to the maintenance department.

Facility Information

Date:	[Date]
Time:	[Time]
Nursing Home Name:	[Your Company Name]
Address:	[Your Company Address]
Phone:	[Your Company Number]
Email:	[Your Company Email]

Requester Information

Name:	[Requester Name]
Phone:	[Requester Number]
Room # (Optional)	[Room Number]

Description of the Issue

Please provide a detailed description of the issue or maintenance request:

Priority Level

Please select the urgency level of the repair:

• Emergency

• Urgent

• Routine

Requested Repair/Maintenance

Please check the appropriate boxes for the requested repair/maintenance:

• Plumbing (e.g., leaking faucets, clogged drains)

• Electrical (e.g., faulty switches, broken lights)

• HVAC (e.g., heating/cooling issues)

• Carpentry (e.g., furniture repairs, door adjustments)

• Painting (e.g., wall touch-ups, trim work)

• Other (please specify):                               

Additional Comments/Instructions

Please provide any additional comments or specific instructions for the maintenance team:

Requested By:

[Requester Name]

[Date]

Acknowledged By:

[Maintenance Staff Name]

[Date]

Thank you for your cooperation. Please submit this form to the maintenance department for processing.

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