In order for us to better serve you, please answer the questions COMPLETELY and give as much detailed information as possible. All fields are REQUIRED fields. This form is for non-emergency help requests. If you have an EMERGENCY and need immediate assistance, please call the District 2 helpdesk at 770-718-5083.
What is the name of the person having the problem?
Complete Name (First, Middle Initial, Last)
In which office are you located?
Select One Banks County Brenau Women's Health Children With Special Needs Dawson County Dawson EH District Office Forsyth County Franklin County Habersham County Hall County Hall EH Hart County Lumpkin County Rabun County Stephens County Towns County Union County White County
What is the room # where the problem exists ?
Is this a new issue or an old one?
Select One New Old
What is the Priority Level for this problem?
Select One Routine Medium High Critical Emergency Routine - a question or clarification of how to perform certain functions. The incident submitter declares no problem. Medium - a problem needs the attention of a support engineer but is not causing a problem that cannot be worked around until the resolution is complete. High - a problem that is causing a limited number of delays in the completion or performance of system functions. Critical - a problem that is causing widespread delays in the completion or performance of system functions. Emergency - a problem that is affecting the entire organization's ability to use the system.
If this is an old issue, what is the Work Order number?
What is the telephone number (direct line or extension #) of the person experiencing the problem? (Please do NOT enter the general front desk#.)
Direct Phone
Are other users experiencing the same problem?
Select One Yes No
Please describe (in detail) the nature of the problem or request.
Does this problem affect the work flow of the clinic? (if yes, please explain)
If work flow of clinic is affected, please describe in detail.
