Open Enrollment Issue Report Form
Report any problems encountered during the open enrollment process to help us resolve them promptly.
Your Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Department or Affiliation
*
Please Select
Human Resources
Finance
IT Support
Academic Affairs
Student Services
Other
Type of Enrollment
*
Benefits Enrollment
Academic Enrollment
Course Registration
Other
Issue Category
*
Please Select
System/Technical Issue
Incorrect Information Displayed
Submission Error
Eligibility Problem
Missing Option
Other
Date Issue Occurred
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Urgency Level
*
Critical (Process Blocked)
High (Needs Immediate Attention)
Medium (Affects Some Processes)
Low (Minor Inconvenience)
Please describe the issue in detail
*
Have you already attempted to resolve the issue? If so, please describe what you tried.
Upload any supporting documents or screenshots (optional)
Upload a File
Drag and drop files here
Choose a file
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of
Preferred Method of Follow-Up
*
Email
Phone
No follow-up needed
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