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Office
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Site Name
Name
*
First
Last
Phone
*
Email
*
Preferred contact method
*
Phone
Email
Name of Computer or Device Affected (if applicable)
New or Existing Issue / Request
*
New
Existing
Not Sure
Priority of Issue / Request
*
High:
Immediately impacts patient care, or system-wide office production
Medium:
Impacts practice efficiency or effectiveness (most common)
Low:
Not urgent, minimal impact to practice
High - our target is 30min or less
Medium - our target is 2hrs or less
Low - our target is within 24hrs
Brief Description of Issue / Request
*
Please provide 1 to 3 sentences which summarizes the issue or request:
Additional Information which may help solve this issue:
Please answer any questions that may be applicable:
Have you had this problem before, if so when?
Have you experienced this issue on any another computers or devices?
Have there been any recent software, hardware, or other technology changes that may coincide with this issue? If so, please explain.
Can you list the specific steps that typically cause this issue?
Best time to remotely connect to this computer or device (if applicable)
ASAP - (no call from SK needed)
ASAP - (SK will call to schedule)
Request a Specific Time/Date
Request a Specific Time/Date
*
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