Health Alert Network Registration Form

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: * E-Mail Fax Pager
* indicates required fields

First Name: *
Last Name: *
Suffix:
Employer:
Address:
City:
State:
Zip Code:
Office Phone Number: *	(Ex: 302-123-4567)
Home Phone Number:	(Ex: 302-123-4567)
Cell Phone Number:	(Ex: 302-123-4567)
Pager Number:	(Ex: 302-123-4567)
Fax Number:	(Ex: 302-123-4567)
Email Primary:
Email Secondary:
Speciality:	(i.e. emergency, infection control, pediatrics, emergency response)
Affiliation: *	(i.e. hospital, city, fire dept., agency, etc.)
Comments:

Last Modified: 5/15/2007