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ITS Phone:

304.293.3631

its@hsc.wvu.edu

P.O. Box 9010

Morgantown, WV 26506

 

MDTV Program Scheduling Request Form


Contact Person: (required)
E-mail Address: (required)
Phone:
Site/Department:
Billing Address: (required)

Program Information
Event Type
Event Name: (required)
Number Attending:
Would you like a DVD of the program? Yes No # of DVD's

Will a presentation be given during this event?
If yes please answer additional questions listed below.

 Yes No

Will this be a single or multi-presenter site conference? (e.g. all presenters are at one location)
Please list locations and requirements for all presenters in the comment section of this form.

 Single Site Multi-Presenter Site
Will the presenter be bringing their own laptop?
Please Note: If a presenter is bringing an Apple Computer it needs to have a DVI output to a VGA connector to ensure proper connection to a projector.		 Yes No

Please check all media requirements that apply to this videoconference.

PowerPoint
DVD
VHS
Music
Other (Please list:)


Single Occurrence Event
Date:
Time: to

Event Series or Class
(Maximum of 12 month period, cannot schedule more than 18 months in advance)
Day(s): M T W TH F SA SU
Begin Date:
End Date:
Time: to

Site Information: Please check each site that you would like to receive the broadcast.

IP Sites
ISDN Sites
Appalachian Community Health Center- Elkins, WV Boone Memorial Hospital - Madison, WV
Braxton Memorial Hospital - Gassaway, WV Charleston Division (WVU)- Charleston, WV
Charleston Division (WVU)- Charleston, WV City Hospital-Martinsburg, WV
Eastern Division (WVU)- Martinsburg, WV Davis Memorial Hospital - Elkins, WV
FMRS Mental Health Council- Beckley, WV Garrett County Memorial Hospital - Oakland, MD
FMRS Mental Health Council- Hinton, WV Harpers Ferry Family Medicine - Harpers Ferry, WV
FMRS Mental Health Council- Union, WV Louis A. Johnson VAMC-Clarksburg, WV
FMRS Mental Health Council- Fayetteville, WV Martinsburg VAMC- Martinsburg, WV
Healthways- Weirton, WV Michael Medical Facility-Moorefield, WV
Minnie Hamilton Health Care Center - Grantsville, WV Mt. Olive Corrections Complex - Mt. Olive, WV
Prestera Center- Huntington, WV Ohio Valley Medical Center - Wheeling, WV
Prestera Center- Charleston, WV Roane General Hospital - Spencer, WV
Princeton Community Hospital - Princeton, WV United Hospital Center - Clarksburg, WV
Sharpe Hospital - Weston, WV West Virginia School of Osteopathic Medicine - Lewisburg, WV
Seneca Mental Health- Summersville 1305 Webster Rd, WV    
Seneca Mental Health- Webster Springs, WV    
Seneca Mental Health- Lewisburg, WV    
Seneca Mental Health- Summersville, WV    
Seneca Mental Health- Marlinton, WV    
Southern Highlands Mental Health Center- Princeton, WV    
Southern Highlands Mental Health Center- Welch, WV    
Southern Highlands Mental Health Center- Mullins, WV    
Valley Healthcare- Morgantown, WV
    
Valley Healthcare- Fairmont, WV    
Valley Healthcare- Grafton, WV    
Valley Healthcare- Kingwood, WV    
Valley Healthcare (ACT) - Pleasant Valley, WV    
Westbrook Health Services- Parkersburg, WV    
Westbrook Health Services- Ripley, WV    

Non - Member Site Information (Please include: Facility Name, Contact Name, Phone and email if available)

Morgantown Room Preference:
Charleston Room Preference (if applicable):

Please note: All rooms listed are able to support a videoconference however not all rooms are equal in technology.
If special interaction or viewing is required for this event please contact our office to ensure the correct room is scheduled.

IMPORTANT:

  • All communications, flyers, press releases, etc., indicating the use of MDTV must first be approved by MDTV.
  • MDTV reserves the right to pre-empt any program in the event of a request for an emergency consultation.
  • Changes or Cancellations? Please contact MDTV at 304.293.3631 (Option 6) as soon as possible.

Additional Comments and Information:


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