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2. First Name*
3. Last Name*
5. Agency*
   -- Select One --Ambulance: Pac WestDispatch: Lincoln CityDispatch: Salem WVCCDispatch: ToledoEmergency Management: CountyFire: Depoe BayFire: NewportFire: North LincolnFire: Seal RockFire: SiletzFire: ToledoFire: Waldport (COCFR)Fire: YachatsLaw: LCSO - JailLaw: LCSO - PatrolLaw: Lincoln CityLaw: NewportLaw: ToledoRoads: CountyAgency - Other
6. Agency - Other
8. Email*
9. Contact Number*
11. Supervisor Name*
12. Supervisor Email*
14. Which system is the issue?*

    1. Fire 1
    2. Fire 2
    3. Law 1
    4. Law 2
    5. Roads
    6. Other
15. Other
17. Severity of issue*

    1. Level 1 - Total loss of communications
    2. Level 2 - Impaired communications
    3. Level 3 - Informative information, upgrades, intermittent problems
19. Source of communication loss*

    1. System
    2. Dispatch
    3. Dispatch Tap-outs
    4. Mobile
    5. Portable
    6. Pager
    7. Other
20. Other
22. Type of communication loss*

    1. Transmitting
    2. Receiving
    3. Both
23. Occurrence*

    1. Just occurred
    2. Continuous
    3. Intermittently
25. Type of audio received*

    1. Tone
    2. Squelch noise
    3. Static
    4. Hum or Buzz
    5. Silent Carrier
    6. None
    7. Other
26. Other
28. Is the issue isolated to a single location or area?*

    1. Yes
    2. No
29. Address or coordinates of location
31. Date of initial occurrence if known
    Date of initial occurrence if known
32. Time of initial occurrence if known
    Time of initial occurrence if known
34. Additional Information
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36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit

* indicates a required field