Help Service Request Form

Please provide the following contact information:

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
FAX
E-mail

Please provide the following client information:

Client/Institution Name
Cerner Client Mnemonic
Cerner Client Number
Cerner Site/Project Contact
Cerner Site/Project Contact Telephone
Cerner Site/Project Contact Email
Cerner Site/Project Contact Pager

Please provide the following system information:

Cerner Platform	Classic 3.06 Classic 3.05 Classic 3.04 Millennium
Operating System	Open VMS AIX Other

For what time period do you want the Help Service to be available?
        3 months         6 months         12 months

Please estimate the number of calls or emails to PCG that you anticipate per month:
        1-15        16-30        31-45        46 or more

What types of PCG Help will you need?

        Answers to questions about CCL.
        Assistance in planning and designing CCL programs.
        System Analysis
        Troubleshooting existing CCL programs
        Other

If Other, please describe:

Are there any special or unusual considerations?        Yes      No

If yes, please describe: