Reporter Name: 
Reporter Phone: 
Reporter Dept: 
Reporter Email: 
Contact information for the resolution resource: 
Partner Service Desk Ticket number: 
Problem Description: 
Affected System/Application(s): 
Is this a Critical Business Application on SSC list: 
Impact on other system (if known): 
Error message(s): 

Scope of Outage: Full, Partial, Degraded or Limited.  Limited refers to a small number of public users, 1 user or redundancy  
How many End Users are impacted(if known): 
Affected End User(s) Name(s): 
Affected End User(s) Phone Number(s): 
Is the issue affecting multiple users for either a Bes or email issue? Y/N 
If yes - Request the emails of some of the affected users(3-5) in order to assist SSC with Troubleshooting: 
If not provided, will affected user list, and emails, be provided at a later time?  Y/N 
Affected End User(s) email address(es): 
Affected End User(s) user ID(s): 
Affected End User(s) Dept.: 
Affected  End User(s) Location(s): 
	Building: 
	Floor: 
	Room: 
Is this affecting the entire building: 
Is this a Designated Site: 

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The following information is to be filled out by the ESD Agent, We do not ask these questions to the Requester.
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Is this affecting a CBAS: 
If yes what is the application name: APPLICATIONIINAME
What are the hours of support for the CBAS: 
Who is the Responsible Incident Coordinators: 
What is the Impact assessment: 
What is the Urgency assessment: 
What is the overall priority of the ticket: 

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