Classroom Improvement Request Form

Please complete this form regularly for all of your classrooms.

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1. First Name (Required.)

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2. Last Name (Required.)

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3. Email (Required.)

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4. Program Name (Required.)

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5. Classroom # (Required.)

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6. Date Checked (Required.)

Date / Time

Date

Time

AM/PM

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7. What needs fixed? (Required.)

	Yes	No	Not Applicable
TeamBoard System	TeamBoard System Yes	TeamBoard System No	TeamBoard System Not Applicable
Lighting/Ceiling Tiles	Lighting/Ceiling Tiles Yes	Lighting/Ceiling Tiles No	Lighting/Ceiling Tiles Not Applicable
Chalkboard/Whiteboard	Chalkboard/Whiteboard Yes	Chalkboard/Whiteboard No	Chalkboard/Whiteboard Not Applicable
Chairs	Chairs Yes	Chairs No	Chairs Not Applicable
Desks/Tables	Desks/Tables Yes	Desks/Tables No	Desks/Tables Not Applicable
Carpets/Flooring	Carpets/Flooring Yes	Carpets/Flooring No	Carpets/Flooring Not Applicable
Electrical Outlets	Electrical Outlets Yes	Electrical Outlets No	Electrical Outlets Not Applicable
Temperature	Temperature Yes	Temperature No	Temperature Not Applicable
Blinds/Curtains	Blinds/Curtains Yes	Blinds/Curtains No	Blinds/Curtains Not Applicable
Computers/Equipment	Computers/Equipment Yes	Computers/Equipment No	Computers/Equipment Not Applicable

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8. Other Comments

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9. If you have any pictures to help demonstrate a classroom problem, please upload them.

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10. If you have any pictures to help demonstrate a classroom problem, please upload them.

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11. If you have any pictures to help demonstrate a classroom problem, please upload them.