VDH Video/Web Conferencing Request Form
All starred (*) items are required. Information provided regarding video conferencing is for confidential use by the Virginia Department of Health and its staff, partners and volunteers. Use of this information is regulated by the Virginia Department of Health Confidentiality Policy (OCOM 1.01).
Requestor Name *
Your answer
Is this video conference for Public Health Preparedness or Emergency Preparedness? *
Requestor District or Office (if VDH)
Your answer
Requestor Organization (if not VDH)
Your answer
Requestor Email Address *
Your answer
Requestor Phone
Your answer
Requestor Cost Code *
For VDH, this will be the 3 digit cost code. For other agencies, this can be whatever cost code is appropriate. This is currently for tracking purposes only.
Your answer
What type of video conference? *
If this is a Web Suite conference, please estimate how many attendees.
Your answer
Video Conference Topic *
Your answer
Video Conference Date(s) *
Your answer
Video Conference Start Time *
Your answer
Video Conference End Time *
Your answer
Video Conference Site of Origination *
This is where the video conference will be broadcast from, usually the place where the presenter will be located. Please include the camera number for VDH sites.
Your answer
Video Conference Additional Sites
If you know other sites that will be connected please list them here and include camera numbers for VDH sites.
Your answer
Special Needs *
Check all that apply. Please note that sessions recorded to the video server are removed after three months. Contact Richard Watson (richard.watson@vdh.virginia.gov) for more details.
Required
Type of Video Conference
Check all that apply.
TRAIN Course ID Number
If this is a training video conference for VDH employees, it must be entered into TRAIN. Please provide the TRAIN Course ID number.
Your answer
Comments
Any additional information you feel may be important.
Your answer
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