Cc: Control Center
Campus Safety
DEPARTMENT NOTIFICATION INFORMATION
Date: _______________ Update: _______________
Department: _________________________ Building: ___________________________
Please complete the personal contact information below for personnel in your department
or responsibility areas to receive notification regarding power outages, flood, heating or cooling
problems or any other concerns. The persons listed need to be familiar with department
equipment, and if additional contacts need to be made within your responsibility area regarding
possible ongoing experiments or further concerns that may need to be addressed.
Procedure: Campus Safety will initiate a text and an email to those listed as your primary
contact. If confirmation of receipt of the message is not received, Campus Safety will attempt to
call the home phone number. If unable to contact the 1
st
contact person, Campus Safety will
proceed to the next person on the contact list.
You may check this box to indicate that your department/responsibility area does not
require notification.
Name of Chair/ Department Head: _____________________ Phone #: ____________
1
st
Contact Person: ____________________________ Cell Phone #: ___________________
Email: ___________________________________ Phone Two #: ___________________
2
nd
Contact Person: ____________________________ Cell Phone #: ___________________
Email: ___________________________________ Phone Two #: ___________________
3
rd
Contact Person: ____________________________ Cell Phone #: ___________________
Email: ___________________________________ Phone Two #: ___________________
Special Attention/Concerns: Please record any items of special consideration or concern or any
equipment or project that would be affected by a loss of any service utilities: (Provide
location/room number and any special handling instructions)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Signature- Dept. Chair: ____________________________ Date: ___________________
Retain a copy for your office: In the event of substantive changes update your copy and forward it to
Campus Safety. Please return this form to the Campus Safety Office as soon as possible. Thank You
click to sign
signature
click to edit
![]()
