Request User Account User Registration Form 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* Ambulatory Surgical Center (ASC) Community Mental Health Center Comprehensive Outpatient Rehabilitation Facility (CORF) End-Stage Renal Dialysis Facility (ESRD) Federally Qualified Health Center (FQHC) Home Health Agency (HHA) Hospice Hospital Intermediate Care Facility-Intellectual Disability Long Term Care Facility (LTCF) Organ Procurement Organization (OPO) Physical Therapy/Speech Language Pathology Therapy Psychiatric Residential Treatment Facility (PRTF) Religious Nonmedical Health Care Institution (RNHCI) Shelter Skilled Nursing Facility (SNF) Transplant Center Partner Agency (not covered by CMS Final EP Rule) Facility Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code This iframe contains the logic required to handle Ajax powered Gravity Forms.