911 PSAP Call Failure Report

This form allows PSAPs to notify DHSES of communications service disruptions that impact 911 call delivery. If your PSAP is experiencing an issue and has opened a ticket with your service provider, please use this reporting mechanism to provide situational awareness to DHSES.

REPORTING ISSUES TO DHSES USING THIS FORM SHOULD BE IN ADDITION TO CONTACTING YOUR SERVICE PROVIDER. DHSES CANNOT ASSUME RESPONSIBILITY FOR ISSUES WITHIN THE CONTROL OF YOUR PSAP OR YOUR SERVICE PROVIDER.

1. If you are part of a County Level PSAP, please select your County of representation from dropdown list:

2. Has your agency submitted an Incident Ticket with your vendor for this issue? *This question is required.

Please provide the date and confirmation/reference number of the submitted Incident Ticket (if known).

Date
Confirmation/Reference #

3. Contact Information *This question is required.

First Name

Last Name

Title

Email Address

Phone Number

4. Please fill out the table below with as much information as known: *This question is required.

	Date of Call Failure:	Time of Call Failure (ET):	Type of Call Failure (Wireline Wireless, VOIP, etc.,)	Affected Phone Number (if known)	Phone Company (if known)	Long Distance Provider (if known)	Current Status (Success or Failure)	What was the problem experienced? (Dead-air, disconnection, no ring, no dial-tone, etc.,)
	Date of Call Failure:	Time of Call Failure (ET):	Type of Call Failure (Wireline Wireless, VOIP, etc.,)	Affected Phone Number (if known)	Phone Company (if known)	Long Distance Provider (if known)	Current Status (Success or Failure)		1.	Date of Call Failure:	Time of Call Failure (ET):	Type of Call Failure (Wireline Wireless, VOIP, etc.,)	Affected Phone Number (if known)	Phone Company (if known)	Long Distance Provider (if known)	Current Status (Success or Failure)	What was the problem experienced? (Dead-air, disconnection, no ring, no dial-tone, etc.,)
2.	Date of Call Failure:	Time of Call Failure (ET):	Type of Call Failure (Wireline Wireless, VOIP, etc.,)	Affected Phone Number (if known)	Phone Company (if known)	Long Distance Provider (if known)	Current Status (Success or Failure)	What was the problem experienced? (Dead-air, disconnection, no ring, no dial-tone, etc.,)
3.	Date of Call Failure:	Time of Call Failure (ET):	Type of Call Failure (Wireline Wireless, VOIP, etc.,)	Affected Phone Number (if known)	Phone Company (if known)	Long Distance Provider (if known)	Current Status (Success or Failure)	What was the problem experienced? (Dead-air, disconnection, no ring, no dial-tone, etc.,)
4.	Date of Call Failure:	Time of Call Failure (ET):	Type of Call Failure (Wireline Wireless, VOIP, etc.,)	Affected Phone Number (if known)	Phone Company (if known)	Long Distance Provider (if known)	Current Status (Success or Failure)	What was the problem experienced? (Dead-air, disconnection, no ring, no dial-tone, etc.,)
5.	Date of Call Failure:	Time of Call Failure (ET):	Type of Call Failure (Wireline Wireless, VOIP, etc.,)	Affected Phone Number (if known)	Phone Company (if known)	Long Distance Provider (if known)	Current Status (Success or Failure)	What was the problem experienced? (Dead-air, disconnection, no ring, no dial-tone, etc.,)
6.	Date of Call Failure:	Time of Call Failure (ET):	Type of Call Failure (Wireline Wireless, VOIP, etc.,)	Affected Phone Number (if known)	Phone Company (if known)	Long Distance Provider (if known)	Current Status (Success or Failure)	What was the problem experienced? (Dead-air, disconnection, no ring, no dial-tone, etc.,)
7.	Date of Call Failure:	Time of Call Failure (ET):	Type of Call Failure (Wireline Wireless, VOIP, etc.,)	Affected Phone Number (if known)	Phone Company (if known)	Long Distance Provider (if known)	Current Status (Success or Failure)	What was the problem experienced? (Dead-air, disconnection, no ring, no dial-tone, etc.,)
8.	Date of Call Failure:	Time of Call Failure (ET):	Type of Call Failure (Wireline Wireless, VOIP, etc.,)	Affected Phone Number (if known)	Phone Company (if known)	Long Distance Provider (if known)	Current Status (Success or Failure)	What was the problem experienced? (Dead-air, disconnection, no ring, no dial-tone, etc.,)
9.	Date of Call Failure:	Time of Call Failure (ET):	Type of Call Failure (Wireline Wireless, VOIP, etc.,)	Affected Phone Number (if known)	Phone Company (if known)	Long Distance Provider (if known)	Current Status (Success or Failure)	What was the problem experienced? (Dead-air, disconnection, no ring, no dial-tone, etc.,)
10.	Date of Call Failure:	Time of Call Failure (ET):	Type of Call Failure (Wireline Wireless, VOIP, etc.,)	Affected Phone Number (if known)	Phone Company (if known)	Long Distance Provider (if known)	Current Status (Success or Failure)	What was the problem experienced? (Dead-air, disconnection, no ring, no dial-tone, etc.,)

5. Please provide any additional questions, comments or concerns.