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EMAN alerts are generally sent by electronic mail. Please be sure your e-mail address is listed correctly. The information you provide is confidential and will not be distributed further. Completing an application does not ensure inclusion in the network. Most applications will be added within 1-2 weeks of submitting this form. Thank you for your interest in EMAN.

Applicant Alerting Profile
(  *  = Required Field)
Prefix:
First Name:   *
Last Name:   *
Organization:   *
Job Title:   *
Degrees:   *
Specify if "other"degree:  
 
Work Contact Information
Work Address:
Work City:  
Work State:   Work Zip:  
Work Email:   *
Work Phone:   (Format: 999-999-9999) *
Work Fax:   (Format: 999-999-9999) 
 
Home Contact Information (for High Priority Alerts only)
Home City:  
Home Zip:  
Home Phone:   (Format: 999-999-9999) 
 
Other Emergency Contact Information
Alternate Email:  
Cell Phone:   (Format: 999-999-9999) 
Alpha Pager Email:  
(Example format: 6195552222@archwireless.net) 
Numeric Pager #:   (Format: 999-999-9999) 
Alternate Phone:   (Format: 999-999-9999) 
 
Miscellaneous Emergency Information
Languages Spoken:
(other than English)		  
Specify if "other languages":  
CPR Certified:
 
Preferred Order of Contact for High Priority Alerts (e.g. public health emergency)
Location 1:   *
Location 2:
Location 3:
Location 4:
Location 5:
 
Preferred Order of Contact for Medium Priority Alerts (e.g. outbreak, unusual disease)
Location 1:   *
Location 2:
Location 3:
 
Preferred Order of Contact for Low Priority Alerts (e.g. disease clusters, surveillance)
Note: Most EMAN alerts are low priority and are issued 1-3 times per month via e-mail only.
Location 1:   *
Location 2:
 
Applicant Security Profile
EMAN Password (minimum length of 6 characters)
Note: All EMAN alerts, including low-priority e-mail alerts, will now require a unique username and password. Choose a memorable, but not obvious, preferred password. When you're notified via e-mail if your application has been accepted, you will be assigned an EMAN username and password at that time.
Preferred Password:   *
Verify Password:   *
 
4-digit Phone Alert Access Code (maximum length of 4 digits)
Note: Use last 4 digits of your Social Security # to help remember this code. If you are alerted by phone, you will need this 4-digit code to identify yourself as the intended phone alert recipient. If you do not pick up the phone, a generic voice mail message will be left on your voice mail, and the 4-digit code will no longer enable you to access the alert.
Phone Alert Access Code:   *
Verify Phone Alert Access Code:   *
 
Do you agree to maintain the confidentiality of information received via EMAN?
Note: Confidentiality means information from EMAN alerts should only be shared within the local medical community. The alerts therefore should not be forwarded, posted or futher distributed.
Confidentiality Agreement:   *
   
Applicant Referral Information
How did you hear about EMAN?
EMAN Referral Source:
Specify if "other referral":  
 

 

Note: If you have difficulty with submitting the online application, please print and fax your completed application to
(619) 515-6644, Attn. EMAN Manager.