This is a form to make the reporting of problems consistent, allow records of problems to be kept, and a method of discouraging users from reporting faults in the first place.
Your name: 
The date? 
The date of the first occurence: 

Problem Severity Minor  Minor  Minor  Minor

Which machine? 

Which areas are at fault?
    Communications    Network
    User              Disk
    Mouse             Rats
    Manufacturer      Screen
    Your manager      Duh I don't know

Is it plugged in?   Yes   No
Is it turned on?   Yes   No
Has it been stolen?   Yes   No
Have you tried to fix it yourself?   Yes   No
Have you made it worse?   Yes   No
Have you read the manual?   Yes   No
Are you sure you read the manual?   Yes   No
Are you absolutely certain you've read the manual?Yes   No
Did you understand it?Yes   No
If `Yes' then why can't you fix it yourself?

Is the equipment unexpectedly noisy?Yes   No
If `Yes', what sort of noise?
Grinding   Whirring
Scraping   Whining
Sandpaper  A pig farting

Is there a smell of burning? Yes   No
If `Yes' is the equipment on fire?   Yes   No
If `Yes', why are you sitting in front of it? 

Is the fault repeatable?   Yes   No
If `no', then why are you worried about it? 
If `yes', then why are you still doing that? 

What were you doing (with the equipment) at the time the fault occurred?

If `nothing' explain why you were logged in.

Are you sure you aren't imagining the problem?   Yes   No
Do you have any independent witnesses of the problem?   Yes   No

Describe the problem.  
Now, describe the problem accurately. 

Speculate wildly about the cause of the problem.