AV Signal Issue Report Form
Please fill out this form to report audiovisual signal problems and help us resolve them quickly.
Reporter Name
*
First Name
Last Name
Contact Email
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Site or Facility Name
*
Room or Device Name/Number
*
Type of Equipment Involved
*
Please Select
Projector
Display/Monitor
Audio System
Switcher/Matrix
AV Receiver
Control Panel
Other
Signal Source
*
Please Select
Laptop/PC
Media Player
Document Camera
Streaming Device
Wireless Presentation
Other
Describe the Issue or Symptom
*
How often does the issue occur?
*
Always
Intermittently
Randomly
Only at certain times
When did the issue first start?
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
What is the impact on operations?
*
Critical – system unusable
Major – significant disruption
Moderate – partial loss of function
Minor – inconvenience only
Troubleshooting steps already attempted
Preferred Callback Method
Email
Phone
No callback needed
Attach Photos or Videos (optional)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Report
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