This form is to be used in the case of theft or losses caused by actions primarily outside of the control of Partners. It is not to be used in the case of fraud or theft by an partner employee, staff members or supplier. Instructions are attached below. The information in this form will be treated by OCHA as STRICTLY CONFIDENTIAL. DATE OF SUBMISSION [DD-MMM-YYYY] SUBMISSION BY [implementing partner / HFU] 1 Project Details – Organization Name: Cluster Project Code: Contact Name: Location: Contact Email/Tel No.: Actual project duration (start and Date of Allocation: end date as grant agreement): Project Title: Amount Allocated: 2 Description of Losses – Type of Loss: Contribution of Other Organizations: Indicate the type (s) of loss reported. If funding or support for items was also provided by other Cash Property donors/organizations, please list them below, and identify: Assets If you selected Assets, Property, or Other, please specify and describe. Please provide summary of items here, and attach a packing list or excel sheet with the items, quantities and costs:: 3 Value of Losses – Provide information the value of the losses. Value of Losses in form of Cash $ % Value of Loss of Assets $ % Value of Loss of Property $ % Value of Loss (Other) $ % Total of Value of Losses $ Please be as specific as possible, and consider that these amounts will be verified through the end of project audit. Please also indicate if any further enquiries or analysis is expected that may provide more details or allow further quantification of the loss.
This form is to be used in the case of theft or losses caused by actions primarily outside of the control of Partners. It is not to be used in the case of fraud or theft by an partner employee, staff members or supplier. Instructions are attached below. The information in this form will be treated by OCHA as STRICTLY CONFIDENTIAL. DATE OF SUBMISSION [DD-MMM-YYYY] SUBMISSION BY [implementing partner / HFU] 1 – Project Details Organization Name: Cluster Project Code: Contact Name: Location: Contact Email/Tel No.: Actual project duration (start and end date as grant agreement): Date of Allocation: Project Title: Amount Allocated: 2 – Description of Losses Type of Loss: Indicate the type (s) of loss reported. Contribution of Other Organizations: If funding or support for items was also provided by other donors/organizations, please list them below, and identify: Cash Property Assets If you selected Assets, Property, or Other, please specify and describe. Please provide summary of items here, and attach a packing list or excel sheet with the items, quantities and costs:: 3 – Value of Losses Provide information the value of the losses. Value of Losses in form of Cash $ % Value of Loss of Assets $ % Value of Loss of Property $ % Value of Loss (Other) $ % Total of Value of Losses $ Please be as specific as possible, and consider that these amounts will be verified through the end of project audit. Please also indicate if any further enquiries or analysis is expected that may provide more details or allow further quantification of the loss.
SHF_IncidentReport_form22d_2017.docx