Product: Internet
Approved by OMB 3060-0874 (Estimated average burden per person is 15 minutes.)
Email address
Subject
Have you contacted your provider about this issue? y/n
Internet issue (drop down)
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
Construction necessary
Other (use description field)
Billing
Service charges
Lifeline
Taxes/fees
Surcharge (including Universal Service)
Advertised rates
Other (use description field)
Equipment
Modems
Other (use description field)
Interference
Jamming/Blocking (including Wi-Fi)
Location/date/time
Other (use description field)
OI/Net Neutrality
Blocking
Data caps
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?
Speed/Service quality
Less than advertised speed
Inconsistent speed
Other (use description field)
Internet method
Fixed Wireless
Mobile Wireless
Cable
Satellite
DSL
Fiber
Wi-fi
Company name (your provider)
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 of your complaint (minus PII) 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 | 2021-08-30 |