Telehealth Network Scheduling Request

*Required Fields


Contact Information

*Requested by:

*Organization:

*Requestor Phone:

*Requestor Email: 

Event Information

*Event Title:

*Start Date:  Calendar
*
End Date: Calendar

*Start Time (actual):  AM PM CT
*End Time (actual): AM PM CT

Video Services starts set ups, including connection, 30 minutes prior to start time.

Event Description/additional scheduling information (excluded dates, special dates, etc.)

if Recurring... Weekly, select day(s) of the week
M   Tu   W  Th  Sa  Su 

List Custom Dates/Times (i.e. 3rd FRI of each month):

Requested Services

Norfolk IP VCR
DVD Recording
There will be charges for DVD recordings. Please provide payment information
Billing Address:

Video Conference Details

Joining a Video Conference

List Originating Site/Contact:

Hosting a Video Conference (designate type)

List distance sites:

Telehealth Consult (distance sites must have encrytption capabilities)

Meeting

Education

Additional Program Information - Outside Nebraska technical support email/phone; Presenter(s) information; specific meeting details, etc.

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Form last updated 10/31/13