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 MonitorFilesFocalPointHeadsetLaptopPayment TerminalPrintingPower BISharepointSystmOne (Authentication, Smartcard, SCR)Microsoft Office (Word, Excel, Powerpoint, Outlook, etc)MobilePhoneTeamsVantageVPNWebsitesWiFi8x8
Specify the underlying cause:*

Login Issue (RA001)Training Issue (RA002)Software issue (RA003)Hardware Issue (RA004)Access to a service or system issue (RA005)
Does this incident apply to:*

One individualMultiple individuals
Risk rate your incident:*

Low-priority incidents are those that do not interrupt people or the business and can be worked around. Services to people and customers can be maintained.Medium-priority incidents affect a few people 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 patient & financial impact.
Main Issue:
Service Level Agreement
Where will you be located for the appointment time?*
Please note we dont offer remote support and have to come on site to fix issues.
Retail admin where will you be located for the appointment time?*
Please note we dont offer remote support and have to come on site to fix issues.
located for the appointment
Suggested Datetime Erdington
Suggested Datetime Selly Park
Select a date and time to suit you availability. However, we will review the details above and prioritise accordingly.
Erdington:*
Selly Park:*
Provide further details:*
Should be Empty:

Incidents

Select a date and time to suit you availability. However, we will review the details above and prioritise accordingly.