FCC Form 1088F Emergency Telephone; Patient Telephone in Hospital, Nurs

DRAFT Not Approved by OMB

3060-0874

Estimated time per response: 30 minutes

Form 1088F – Emergency Telephone; Patient Telephone in

Hospital, Nursing Home, or Elderly Care Facility Complaint

Consumer's Information:

First Name: _______________________ Last Name: ___________________

Company Name: ______________________________________________________________________

(Complete only if you are filing this complaint on behalf of a company or an organization.)

Street Address or Post Office Box Number: ________________________________________________

City: ___________________ State: ___________________ Zip Code: ___________________

Telephone Number: (____) ____ - _______  Ext: _____

* * * Answer each question that applies to your specific complaint. * * *

Background information is at the end of this section.

1. Call(s) made to

___emergency telephone line(s)

___patient or guest room(s) in health care facility or elderly home

2. Telephone number(s) at which your facility received the call(s). You do not need to enter more than four numbers but if you received calls on more numbers, explain below.

(____) ____ - _______ (____) ____ - _______

(____) ____ - _______ (____) ____ - _______

_________________________________________________________________________________

_________________________________________________________________________________

3. When did you receive the call(s)?

Date ___/___/____ Time ___:___  AM  PM Date ___/___/____ Time ___:___  AM  PM

Date ___/___/____ Time ___:___  AM  PM Date ___/___/____ Time ___:___  AM  PM

4. Did you receive caller ID information for the call(s) in question?

___Yes ___No ___Don’t have caller ID (If you answer No or Don’t Have, skip to question 5.)

Information obtained through caller ID: (____) ____ - _______

Business name __________________________________________

Did the caller ID information accurately report the name and/or calling number for the call in question?

___Yes

___No How did you determine it was not accurate? ______________________________________

___Not certain

5. Was the following information provided DURING the call/message?

Name of the business, individual, or other entity responsible for the call/message ___ Yes ___ No

Name(s) provided ___________________________________________________

Was this provided at the beginning of the call/message? ___ Yes ___ No

Business telephone number for the entity responsible for the call/message ___ Yes ___ No

Numbers provided: (____) ____ - _______  (____) ____ - _______

Other information provided _________________________________________________________

Did you listen to the entire call/message? ___ Yes ___ No

6. List any names, telephone numbers, or other identifying information (e.g., addresses, websites) you obtained through other means (e.g., reverse call back through *57 or your own research).

(____) ____ - _______  (____) ____ - _______ (____) ____ - _______

Business name(s) _________________________________________________________________

Other information _________________________________________________________________

How did you obtain this information? _________________________________________________ ________________________________________________________________________________

7. Did the call(s) indicate any emergency purpose (a necessary communication in any situation affecting the health and safety of consumers)? ___Yes ___No (If you answer No, skip to question 8.)

Describe _____________________________________________________________________

_____________________________________________________________________________

8. Did you or anyone at your facility give prior express permission for the call(s) to be made?

___Yes ___No

9. TYPE OF CALL(S) Select one:

___Live (voice) call

Describe _________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

___Prerecorded message

Describe _________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

___“Dead air” or automated tones

Describe _________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

___None of the above

Describe _________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

10. Did any prerecorded message disconnect promptly (within about 5 seconds) after you hung up?

___Yes

___No Describe _________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

___Not certain

Continue to the Attestation Page to Complete Your Complaint

BACKGROUND

The FCC prohibits the use of automatic telephone dialing systems or prerecorded messages to call:

• any emergency telephone line, including any 911 line and any emergency line of a hospital, medical physician or service office, health care facility, poison control center, or fire protection or law enforcement agency; or,

• any guest or patient room of a hospital, health care facility, elderly home, or similar establishment

UNLESS the call is made for an emergency purpose or with the called party’s prior express permission.

You may not know whether or not a call you received used an automatic telephone dialing system. Calls to multiple telephone lines in quick succession often involve an automatic dialing system. Automatic dialing systems are used by many entities that regularly make calls to large numbers of telephone lines including telemarketers who rely heavily on such systems to conduct their business.

Determining whether an automatic dialing system has been used to make a particular call can be difficult. The more details you are able to provide, the greater the likelihood that the FCC will be able to determine whether a violation has occurred that could lead to an enforcement action.

ATTEST TO THE ACCURACY OF YOUR COMPLAINT Thank you for filing your complaint. Your complaint will be most useful to us if you execute this sworn statement. The FCC will make every effort to take enforcement action against any party who violated the FCC's rules.

Fill in the blanks below and then check the “EXECUTE” box, to declare under penalty of perjury that the information you have provided is, to the best of your knowledge, true and correct.

I declare under penalty of perjury that (1) I am over 18 years old, (2) I am authorized to make decisions regarding the telephone number listed below, and (3) the information I have provided today on this Federal Communications Commission form is, to the best of my knowledge, true and correct.

___________________________________(name) ____________________(date)  EXECUTE

(____) ____ - _______ (telephone number where you received the call(s) that is the subject of your complaint)

You may submit this form over the Internet at http://www.fcc.gov/cgb/complaints.html, by e-mail to [email protected], by fax to 1-866-418-0232, or by postal mail to:

Federal Communications Commission
Consumer & Governmental Affairs Bureau
Consumer Complaints
445 12th Street, SW
Washington, D.C. 20554.

In addition, you may submit your complaint over the telephone by calling 888-CALL-FCC. If you choose to submit your complaint over the telephone, an FCC customer service representative will fill out an electronic version of the form for you during your conversation. If you have any questions, feel free to contact the FCC at 888-CALL-FCC.

FCC NOTICE REQUIRED BY THE PAPERWORK REDUCTION ACT AND THE PRIVACY ACT

The Federal Communications Commission is authorized under the Communications Act of 1934, as amended, to collect the personal information that we request in this form. This form is used for complaints that involve (1) junk faxes, (2) telemarketing (including do-not-call violations), and (3) other related issues such as prerecorded messages, automatic telephone dialing systems, and unsolicited commercial email messages to wireless telecommunications devices. The public reporting for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the required data, and completing and reviewing the collection of information. If you have any comments on this burden estimate, or how we can improve the collection and reduce the burden it causes you, please write to the Federal Communications Commission, OMD-PERM, Paperwork Reduction Project (3060-0874), Washington, DC 20554. We will also accept your comments regarding the Paperwork Reduction Act aspects of this collection via the Internet if you send them to [email protected]. PLEASE DO NOT SEND YOUR COMPLETED FORMS TO THIS ADDRESS.

Remember - You are not required to respond to a collection of information sponsored by the Federal government, and the government may not conduct or sponsor this collection, unless it displays a currently valid OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-0874.

In addition, the information that consumers provide when filling out FCC Form 1088 is covered by the system of records notice, FCC/CGB-1, Informal Complaints and Inquiries File (Broadcast, Common Carrier, and Wireless Telecommunications Bureau Radio Services). The Commission is authorized to request this information from consumers under 47 U.S.C. 206, 208, 301, 303, 309(e), 312, 362, 364, 386, 507, and 51; and 47 CFR 1.711 et seq.

Under this system of records notice, FCC/CGB-1, the FCC may disclose information that consumers provide as follows: when a record in this system involves a complaint against a common carrier, the complaint is forwarded to the defendant carrier who must, within a prescribed time frame, either satisfy the complaint or explain to the Commission and the complainant its failure to do so; where there is an indication of a violation or potential violation of a statute, regulation, rule, or order, records from this system may be referred to the appropriate Federal, state, or local agency responsible for investigating or prosecuting a violation or for enforcing or implementing the statute, rule, regulation, or order; a record from this system may be disclosed to a Federal agency, in response to its request, in connection with the hiring or retention of an employee, the issuance of a security clearance, the reporting of an investigation of an employee, the letting of a contract, or the issuance of a license, grant or other benefit; a record on an individual in this system of records may be disclosed, where pertinent, in any legal proceeding to which the Commission is a party before a court or administrative body; a record from this system of records may be disclosed to the Department of Justice or in a proceeding before a court or adjudicative body when: (a) the United States, the Commission, a component of the Commission, or, when represented by the government, an employee of the Commission is a party to litigation or anticipated litigation or has an interest in such litigation, and (b) the Commission determines that the disclosure is relevant or necessary to the litigation; a record on an individual in this system of records may be disclosed to a Congressional office in response to an inquiry the individual has made to the Congressional office; a record from this system of records may be disclosed to GSA and NARA for the purpose of records management inspections conducted under authority of 44 U.S.C. 2904 and 2906. Such disclosure shall not be used to make a determination about individuals.

In each of these cases, the FCC will determine whether disclosure of the information in this system of records notice is compatible with the purpose for which the records were collected. Furthermore, information in this system of records notice are available for public inspection after redaction of information that could identify the complainant or correspondent, i.e., name, address and/or telephone number.

THE FOREGOING NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507 AND THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974, 5 U.S.C. SECTION 552a(e)(3).