NDHAN ALERT REQUEST FORM
Type of Alert:
Severity of Alert: Please select Severity of AlertExtremeSevereModerateMinorUnknown Please select Severity of Alert Activate: ImmediateSchedule (Date & Time) Delivery Method (check all that apply): VoiceEmailText Alert Details Require Live Answer Confirm Receipt (requires Live Answer) Call Voice 1 only # of Call Attempts: Notification Groups: Notification Groups field is required Notification Message: Email Attachment: Requestor Information Requesting Facility (please include region): Facility Phone Number (This is the number you want displayed in the Caller ID): Contact Name: Contact Email: Email field is required Not a valid email address Route to Incident Commander for Approval if Required * Enter the code shown on the left:
Severity of Alert: Please select Severity of AlertExtremeSevereModerateMinorUnknown Please select Severity of Alert
Activate: ImmediateSchedule (Date & Time)
Delivery Method (check all that apply): VoiceEmailText
# of Call Attempts:
Notification Groups: Notification Groups field is required
Notification Message:
Email Attachment:
Requesting Facility (please include region):
Facility Phone Number (This is the number you want displayed in the Caller ID):
Contact Name:
Contact Email: Email field is required Not a valid email address
Route to Incident Commander for Approval if Required