First Name:
Last Name:
Agency:
Agency Address:
ZIP Code:
County: Anderson Andrews Angelina Aransas Archer Armstrong Atascosa Austin Bailey Bandera Bastrop Baylor Bee Bell Bexar Blanco Borden Bosque Bowie Brazoria Brazos Brewster Briscoe Brooks Brown Burleson Burnet Caldwell Calhoun Callahan Cameron Camp Carson Cass Castro Chambers Cherokee Childress Clay Cochran Cockran Coke Coleman Collin Collingsworth Colorado Comal Comanche Concho Cooke Coryell Cottle Crane Crockett Crosby Culberson Dallam Dallas Dawson DeWitt Deaf Smith Delta Denton Dickens Dimmit Donley Duval Eastland Ector Edwards El Paso Ellis Erath Falls Fannin Fayette Fisher Floyd Foard Fort Bend Franklin Freestone Frio Gaines Galveston Garza Gillespie Glasscock Goliad Gonzales Gray Grayson Gregg Grimes Guadalupe Hale Hall Hamilton Hansford Hardeman Hardin Harris Harrison Hartley Haskell Hays Hemphill Henderson Hidalgo Hill Hockley Hood Hopkins Houston Howard Hudspeth Hunt Hutchinson Irion Jack Jackson Jasper Jeff Davis Jefferson Jim Hogg Jim Wells Johnson Jones Karnes Kaufman Kendall Kenedy Kent Kerr Kimble King Kinney Kleberg Knox La Salle Lamar Lamb Lampasas Lavaca Lee Leon Liberty Like Oak Limestone Lipscomb Live Oak Llano Loving Lubbock Lynn Madison Marion Martin Mason Matagorda Maverick McCulloch McLennan McMullen Medina Menard Midland Milam Mills Mitchell Montague Montgomery Moore Morris Motley Nacogdoches Navarro Newton Nolan Nueces Ochiltree Oldham Orange Palo Pinto Panola Parker Parmer Pecos Polk Potter Presidio Rains Randall Reagan Real Red River Reeves Refugio Roberts Robertson Rockwall Runnels Rusk Sabine San Augustine San Jacinto San Patricio San Saba Schleicher Scurry Shackelford Shelby Sherman Smith Somervell Starr Stephens Sterling Stonewall Sutton Swisher Tarrant Taylor Terrell Terry Throckmorton Titus Tom Green Travis Trinity Tyler Upshur Upton Uvalde Val Verde Van Zandt Victoria Walker Waller Ward Washington Webb Wharton Wheeler Wichita Wilbarger Willacy Williamson Wilson Winkler Wise Wood Yoakum Young Zapata Zavala
Agency Type Association College/University County Govt EOC Emergency Medical Service Full Service-LHD Hospital Industry Law Enforcement Municipal Govt Non-Full Service-LHD Not Selected Other Contact Other Health Facility Poison Center School TDH-Central Office TDH-Regional Office
Profession or Job Type:
None Administrator, Other Agency Commissioner/Director Attorney BT Planner Clerical Support County Commissioner/ County Judge/Mayor County Coroner/Morgue Day Care Emergency Management Emergency Medical Services (EMS) Environmental Health Epidemiology Epidemiology Response Team (ERT) Fire/Hazmat Food Services HAN Administrator Health Authority Homeland Security Hospital Infection Control Practitioner Infectious Disease Specialist Lab Law Enforcement Mental Health Network Support Specialist None Nurse Other Health Professional Paramedic Pediatrician Pharmacy Physician Program Manager Public Information SNS/NPS Volunteer School Nurse School Official Social Worker Translator Veterinary/Zoonosis Vital Statistics Volunteer
Job Title:
Level of Education:
Please Select M.D. D.O. MPH Epidemiology Paramedic EMT RN LVN
Contact Order:
Please Select Primary Contact Second Contact Third Contact
Telephone Numbers
Home:
Cell:
Pager:
Work:
Work Fax:
Email Address:
Alternate Email Address:
Preferred Method of Contact After Hours:
Please Select Home Phone Cell Phone Pager Alternate Email