Safety & Loss Prevention
Quarterly Expenditure Submittal Form
LOSS PREVENTION AND CONTROL
CONTRACTUAL SERVICES
QTRLY. EXPENDITURE SUBMITTAL
INSTITUTION_________________________________________________________________
Expenditure/s for Quarter______ Fiscal Year______
(Please check the appropriate column for each service/item listed)
|
Vendor Name |
Description of Services/Items |
Injury Reduction |
Compliance |
Cost |
|
| |
| |
|
|
|
|
| |
| |
|
|
|
|
| |
| |
|
|
|
|
| |
| |
|
|
|
|
| |
| |
|
|
|
|
| |
| |
|
|
|
|
| |
| |
|
|
|
|
| |
| |
|
|
|
|
| |
| |
|
|
|
|
| |
| |
|
|
|
|
| |
| |
|
|
|
|
| |
| |
|
|
|
|
| |
| |
|
|
|
|
| |
| |
|
|
|
|
TOTAL |
|
Submitted by: ________________________________________
Return Form To:
UW System Administration
Office of Safety & Loss Prevention
Attn: Dawn Holt
POB 8010
Madison, WI 53715-2635
FAX: (608) 262-8589
Email: dholt@uwsa.edu