EMERGENCY OUTAGE NOTIFICATION

After completing this form, please send to faccomm@central.uh.edu for processing.

Informational Messages
OUTAGE PURPOSE: (insert brief overview statement to include why the outage is needed – i.e. new breaker installation, water leak repair, valve installation)
IMPACT MESSAGE: (insert brief statement to help the user understand what the outage will mean for them and their use of the building – i.e. no water during the outage or full power outage or blips)
Outage Schedule / Building(s)
Outage Start Date:	(day of week, mm/dd/yy)	Outage End Date:	(day of week, mm/dd/yy)
Start Time:	(outage start time)	End Time:	(outage end time)
Building(s) Affected:	(building name)	Building No:	(building number)
Building(s) Affected:	“ “ “	Building No:	“ “ “
Building(s) Affected:	“ “ “	Building No:	“ “ “
Building(s) Affected:	“ “ “	Building No:	“ “ “
Type of Outage
Electric	Gas	Domestic Cold Water
DI Water	Condensate	Domestic Hot Water
Steam	Compressed Air	Chilled Water
Vacuum	Air Handling Unit	OTHER
Primary Outage Contact
Primary Contact:	Please call the Facilities Service Center, 24/7, at 713-743-4948 (FIXIT) to reach the Primary Outage Contact.
Secondary Contact:
Onsite Contractor Contact
Primary Contact:	Position:
Telephone:	Email:
Secondary Contact:	Position:
Telephone:	Email:
Outage Review and Approval Process (FS Communications Office Use Only)
Outage Requested by:	Request Date:
Outage Approved by:	Approval Date:
Outage Notice Issued by:	Issue Date:
Building Coordinator:	Sign Off Date:
Fire Marshal:	Sign Off Date: