Broadband Speed Test and Unavailability Registry

Approved by OMB
3060-1129
Expires 02/28/2013

BROADBAND DEAD ZONE REPORT
The Broadband Dead Zone Reporting Form provides your household with the opportunity to
voluntarily participate in the FCC’s effort to pinpoint areas in the United States where
Americans are unserved or underserved by broadband access. Should you choose to
complete this voluntary form, please note that the information you provide will not be used
for purposes other than what is stated herein nor will it be disclosed outside the government.

*Do you have broadband internet access available at your home: ___Yes ___No
If “Yes”, what type(s) of Broadband Internet access are available at your home?
___ Fixed Wired connection (Cable, DSL or Fiber Optic)
___ Mobile or fixed wireless connection (such as an AirCard or WiMax)
___ Satellite
___ Other

If broadband or additional broadband service options were available in your area, would you
be interested in purchasing such service? ___Yes ___No

*Your current location:
Street Address:
_______________________________________
Address 2:
_______________________________________
City:
_____________________
State:
_______________
Zip:
_______________

* Denotes required information

For questions, or to submit your information over the telephone, call 1-888-CALL-FCC (TTY: 1-888-TELL FCC).
This information can be submitted on the Internet at http://broadband.gov/quality-test/deadzone.html
Information may also be submitted by sending all required information by e-mail to [email protected], by fax to
1-877-627-7460, or by postal mail to:
Federal Communications Commission
Consumer & Governmental Affairs Bureau
ATTN: Broadband Unavailability Reporting
445 12th Street, SW
Washington, D.C. 20554