Request User Account

Name*

First Last

Email*

Office Phone*

Cell Phone*

24/7 Emergency Phone*

In the event of an emergency at your facility, please indicate the phone number of your point of contact. This could be the administrator on call, security officer, ED charge nurse, or other. This number should be monitored 24/7 to ensure that CDPH/City of Chicago can contact someone at your facility during emergency operations day or night. This number will remain confidential and will only be used in case of emergency.

Username*

Password*

Enter Password Confirm Password

Title (e.g. Administrator, EP Coordinator, etc.)*

Organization Name*

Who is the primary person responsible for emergency preparedness at your organization?*

Facility Type*

Facility Address*

Street Address Address Line 2 City State ZIP Code

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