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2. Contact Information
4. User First Name*
5. User Last Name*
6. Unit #*
8. Agency*
   -- Select One --Camden County Fire RescueCamden County Sheriff's OfficeKingsland Fire RescueKingsland Police DepartmentSt. Marys Fire DepartmentSt. Marys Police Department
10. Phone Number*
11. Alternate Phone Number
13. Email Address*
17. Problem Description
19. Date and Time of Problem*
    Date and Time of Problem

    Date and Time of Problem
20. Location of Problem*
22. Problem Type*

    1. New Problem

    1. Existing Problem
24. Describe the problem in detail:*
28. Radio Information
30. Radio Make*
    -- Select One --HarrisKenwoodMotorolaTaitOther
32. Radio Model*
33. Radio ID (if known)
35. If portable radio, was a public safety external microphone being used at the time?*

    1. Yes

    1. No

    1. N/A - Not a Portable Radio
37. If portable radio, was it being used in a vehicle or inside a building?*

    1. Yes

    1. No

    1. N/A - Not a Portable Radio
39. If mobile, was vehicle in motion at the time of the problem?*

    1. Yes

    1. No

    1. N/A - Not a Mobile Radio
41. What Channel was being used at the time of the problem?*
43. Who were you talking to/trying to talk to at the time of the problem?*
45. If known, where was the other vehicle at the time of the problem?
49. System Information
51. Was the problem experienced on all channels?*

    1. Yes

    1. No
53. Was the problem experienced on only one channel?*

    1. Yes

    1. No
55. If yes, please identify which channel.
59. Disclaimer: Information submitted on this form will be sent via email. To protect sensitive information, do not submit the following information on this form: Social Security numbers, driver’s license numbers, bank account information, routing numbers, medical information, passport numbers, and passwords.
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63. 1. Receive an email copy of this form.
64. Email address

    This field is not part of the form submission.

65. Submit Submit and Print

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