Maintenance & Repair Request Form

Brooklyn Center, MN • Serving Twin Cities Metro State Licensed & Insured Care

Office: 763-270-5771 | 24/7 On-Call Support

Requestor Information

Provide your contact details so our maintenance department can follow up.

Full Legal Name *

Phone Number *

Email Address *

Your Role *

Resident Employee Manager/Supervisor Family/Representative Vendor Other

Priority Level *

Select urgency to help dispatch the right team quickly.

EMERGENCY

Immediate danger to person or property (water flood, gas smell, electrical spark)

URGENT

Requires attention as soon as possible (no heat/AC in extreme weather, broken lock)

ROUTINE

Repair needed; no immediate safety concern (slow drain, squeaky door, light bulb)

LOW PRIORITY

Cosmetic or non-urgent maintenance (touch-up paint, minor furniture wear)

Description of Problem *

Provide thorough details to ensure accurate diagnosis.

Describe the maintenance issue in detail: *

Date first noticed:

Time first noticed:

Is the problem getting worse?

Yes No Unsure

Does this affect a resident's health, safety, mobility, or ability to use the area?

Yes No

Photo / Document Attachment

Attach photos or documents showing the maintenance issue, if available.

Click to upload files or drag and drop

Photos help our maintenance team bring the exact replacement parts.

Permission to Enter

Provide entry authorization for resident room or private unit repairs.

If the issue is inside a resident room/unit, may authorized maintenance personnel enter?

Yes (Anytime during business hours) Yes, but staff must be present Contact before entering Not applicable (Common area / Exterior)

Preferred maintenance time:

Submission & Certification

Sign electronically to confirm the accuracy of your maintenance report.

By submitting this request, I certify that the information provided is accurate to the best of my knowledge.

Requestor Signature Name *

Date of Submission *

Digital Signature (Draw or Touch):

Use your finger, stylus, or mouse to sign above.

Security Verification *

Verifying you are human helps prevent automated spam submissions.

CONFIDENTIALITY NOTICE: Do not include a resident's diagnosis, medical information, Social Security number, or other confidential health information on this routine maintenance form unless specifically required and authorized.

Requestor Information

Location of Maintenance Issue

Type of Maintenance Request *

Priority Level *

Description of Problem *

Photo / Document Attachment

Permission to Enter

Submission & Certification

Reliable Care. Real Support. Right Where You Are.

MAINTENANCE & REPAIR REQUEST FORM

Requestor Information

Location of Maintenance Issue

Type of Maintenance Request *

Priority Level *

Description of Problem *

Photo / Document Attachment

Permission to Enter

Submission & Certification

Reliable Care. Real Support. Right Where You Are.

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