Incident Form

Incidents

An incident is an unplanned interruption, or reduction in the quality of service.
Project
First Name*
Last Name*
Name*

First NameLast Name
Your Email or someone else's if required*
Please use your Birmingham Hospice email address, not NHS Mail
Phone Number:*
Please enter a valid phone number - include area code.
Please tell us the site location your requesting support at:*

ErdingtonRemoteSellyOak
Which department do you belong to?
Example: IPU, H@H, PHB, People Team
Which Department are you located at?*
What type of incident are you raising?:*

Fix or Repair HardwareReplaceRectify
Category
And what service or product would the incident apply to :*

CitrixDesk PhonesDesk Setup (Docking Station, Monitors)DonorflexEmails - Birmingham HospiceEmails - NHSExternal MonitorFilesFocalPointHeadsetLaptopLogin (Username or Password)LotusPayment TerminalPrintingPower BISharepointSystmOne (Authentication, Smartcard, SCR)Microsoft Office (Word, Excel, Powerpoint, Outlook, etc)MobilePhoneTeamsVantageVPNWebsitesWiFi8x8
Specify the issue:*

Login Issue (RA001)Training Issue (RA002)Software issue (RA003)Hardware Issue (RA004)
Specify the issue:*

Login Issue (Bitlocker problem) (RA001)Login Issue (Password/Pin problem) (RA001)Hardware (Faulty) (RA004)
Because you selected SystmOne, we can only ensure that your S1 program and card reader works, please contact Julie Dyche for all other issues.

Card Reader or smart card not being recognisedSystmOne does not open
Does this incident apply to:*

An individualA Department
Risk rate your incident:*

Low-priority incidents are those that do not interrupt users or the business and can be worked around. Services to users and customers can be maintained.Medium-priority incidents affect a few staff and interrupts work to some degree. People may be slightly affected or inconvenienced.High-priority incidents affects a large number of people or customers, interrupt business, and affect service delivery. These incidents almost always have a financial impact.
Main Issue:
Provide further details:*
Service Level Agreement
Where will you be located for the appointment time?*
Suggested Datetime Erdington
Suggested Selly Park
Tell us your offsite address.

So we can provide support to you.
1st Line of your address:*
House/ Apt Number and Street Name
City:*
Which City is this?
Postcode:*
Whats the postcode
Preferred Availability

We will try and match your availability
Erdington:*
Selly Park:*
Should be Empty:

Incidents

Tell us your offsite address.

Preferred Availability