Staff Electronic Device Request Form

Please complete the form below. Required fields marked with an asterisk *

Staff Member Name*

Answer Required

NYC Schools (DOE) Email*

Answer Required

I prefer the following device:*

Answer Required

Windows Laptop (ex: Lenovo)

MacBook

I have no preference

Chromebook (NO HDMI)

Other:

If "Other" please briefly explain specific requirements below:

Answer Required

I understand that this device is to be provided to me on a "loan" basis. The device and/or accessories must be returned to the High School for Health Professions and Human Services at the end of the school year (or immediately upon resignation/termination).*

Answer Required

Yes, I agree to the above statement

I agree to complete the "Equipment Utilization Form" available in the Teachers section of our school website upon receiving an electronic device.*

Answer Required

Yes

I am available to pick up an electronic device from room 208A during the following periods:*

Answer Required

Period 0

Period 1

Period 2

Period 3

Period 4

Period 5

Period 6

Period 7

Period 8

Please fix the highlighted areas below before submitting.

Staff Electronic Device Request Form

Please complete the form below. Required fields marked with an asterisk *