Product: phone
Approved by OMB 3060-0874 (Estimated average burden per person is 15 minutes.)
Email address
Subject
Phone issue (drop down)
Unwanted calls/messages (telemarketing calls, prerecorded messages, advertising and mass texts)
Telephone number where you received the unwanted call/message
Your phone type/location (residential/personal, business (including government and nonprofit organizations), patient room in health care or elderly care facility, Emergency phone line, toll free line)
Date of unwanted call
Type of call/message (live voice, prerecorded voice, test message, abandoned call)
Have you or anyone in your household or business given the caller/company permission to call? y/n/uncertain
Did the call/message that you are reporting advertise any type of goods, or services? y/n
If yes: type of property, goods, services
Have you or anyone else in your household done any business with the caller/company within the 18 months immediately before you received the call/message? y/n/uncertain
Do you or anyone in your household have a personal relationship with the individual who made the call? y/n/uncertain
Did you receive caller ID information? y/n/uncertain/don’t have caller ID
If yes: caller ID number
Caller ID name
Was the caller’s business name and/or phone number provided DURING the call/message? Only provide information received during the call itself, NOT caller ID information. y/n/uncertain
If yes: business name
Business phone number
Provide any additional information you would like to share about this call or your interactions with this caller.
Junk faxes
Did the fax advertise any type of property, goods, or services? y/n
If no: do not accept complaint
If yes: type of property, goods, or services. This screen must be populated.
Date you received the fax
Provide a copy of the fax OR advertiser’s phone number and name
Have you or anyone else in your household or business given the fax advertiser permission to fax? y/n/uncertain
Have you or anyone else in your household or business done any business (including an inquiry or application) with the fax advertiser? y/n/uncertain
Provide any additional information you would like to share about this fax or your interactions with this advertiser.
Availability
Coverage areas/coverage maps
Additional charge to make service available
Amount of charge
Reason for charge
Estimated time frame to complete
No service available
Outside service area
Other (use description field)
Billing
Service charges (recurring charges, roaming, ETFs)
Lifeline
Taxes/fees/Surcharge (including Universal Service)
Advertised rates
Inmate calling
Other (use description field)
Cramming
Name of Company responsible for unauthorized charge
Confirm copy of bill attached (check box)
Equipment
Device unlocking
Other (use description field)
Interference
Signal jammers
CB radio
Amateur radio
Other (use description field)
Number portability
OI/Net Neutrality
Blocking
Data caps
Speed
Throttling
Inaccurate disclosures/Transparency
Other (use description field)
Privacy
Has your personal information been accessed, obtained or used by an unauthorized person? y/n
If yes:
Describe what personal information has been accessed, obtained or used
Describe how you discovered your personal information had been accessed, obtained or used
Did you receive written notice from your provider about the data breach? y/n
If yes, attach or describe the notice, include the date you received the notice and what it contained
Did you have previous security concerns about your provider?
If no: use description field to describe your issue
Rural call completion
Telephone number called
Telephone number calling you are calling from
Date/time of call
Caller’s long distance provider (not required)
Are you a service provider filing on behalf of a customer? Y/N
Service quality/repair
Slamming
Confirm wireline phone (check box)
Confirm copy of bill attached (check box)
State for slamming
Residential or business phone
Local telephone provider
Long distance provider
Back with authorized provider? y/n
Disputed charges paid
Disputed charges adjusted/refunded
Amount of charges
Amount adjusted
Phone method
Wired
Wireless
VoIP
Telephone number subject of complaint
Company name
Are you a current, former, or prospective customer of this company?
Current
Former
Prospective
Other
Have you contacted this provider about this issue? y/n
Have you filed a complaint about this issue in the past 90 days?
Account number
First name/Last name
Address/city/state/zip code
Phone (where you can be contacted)
Filing on behalf of someone
If yes, your relationship (on behalf of)
First name (on behalf of)
Last name (on behalf of)
Company name (on behalf of)
Address (on behalf of)
City (on behalf of)
State (on behalf of)
Zip code (on behalf of)
Description of complaint (free text field)
Can the FCC share your description (minus PII) of your complaint with the public on our website? y/n
Attachments
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Kimberly Wild |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |