Confidential Delaware Health Alert Network
Department of Health and Social Services
Division of Public Health     			

The Delaware Health Alert Network (DHAN) is part of a nationwide network of public health
agencies used to communicate terrorism and other public health threats via email or telefax.
The Delaware Division of Public Health manages the DHAN.  We encourage you to register for this
service today by returning this application so we can provide you with timely updates.

ATTENTION:  THE Delaware Health Alert Network (DHAN) IS A SECURE DATABASE,
THE INFORMATION WILL NOT BE SHARED OR SOLD IN ANY WAY.

Please check the notification service you desire.  (* indicates required fields)
0   E-mail 		0	Fax Messaging 	0	Pager	

Please complete the information below: Please Print Legibly.

First Name:*_________________________ Last Name*____________________________________ Suffix______

Employer_________________________________________________________________________________________

Street Address___________________________________________________________________________________

City__________________________________________________  State_____________    Zip________________

Phone:  Office*_________________________ Home______________________ Cell_________________________

Pager______________________________________ Fax* ________________________________________________

Email Primary*___________________________________________________________________________________

Email Secondary__________________________________________________________________________________

Specialty (i.e. emergency, infection control, pediatrics, emergency response,)___________________

Affiliation* (i.e. hospital, city, fire dept., agency, etc.)_____________________________________

Comments:________________________________________________________________________________________

Submit or update your information by contacting Cheryl Oliver-Knight via email to cheryl.oliver-
knight@state.de.us or fax to 302-739-6627 or mail to Jesse Cooper Bldg, SLC D320A, 417 
Federal Street, Dover, DE 19901
			
Doc. #35-05-20/08/01/11
Updated 1/14/2008