Category: Internet
Not Yet Approved by OMB 3060-0874 (Estimated average burden per person is 15 minutes.)
Privacy Statement
Email address
Internet issue
Availability
Inaccurate Coverage areas/coverage maps
No internet deployment/service in my area
Inadequate network upgrades
Inadequate network maintenance
Additional charge to make service available
Outages or Inconsistent Availability
Other (use description field)
Speed
Inadequate internet speed
Less than advertised speed
Inconsistent speed
Low data caps
Throttling (intentional slowing of internet speed)
Failure to undertake advertised service upgrade
Other
Billing or Pricing
Advertised rates
Service charges or deposits
Lifeline/USF
Taxes/fees/surcharges
Late fees (excessive or over-charged)
Credit check
Service suspension or termination without notice
Other
Equipment
Modems
Problems with service installation on site
Other (use description field)
Broadband Label
Monthly, one-time, or early termination fees
Discounts and bundles
ACP
Speeds
Data
Incomplete List of Fees
Label Accessibility
Not in Language Marketed to
Broken Links
Legibility and visibility
Other
Interference
Jamming/Blocking (including Wi-Fi)
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?
Does your complaint involve digital discrimination of access based on income level, race, ethnicity, color, religion, or national origin? y/n/Don't know
If yes:
Which of the following characteristics is your digital discrimination of access complaint based on? (Multi-select)
income level
race
ethnicity
color
religion
national origin
none of the above
Is the digital discrimination of access complaint you have happening at your residence or another location?
Residence
Another Location
Type of Location
School
Library
Public commercial location
Other
City of Location
State of Location
Zip of Location
Do other members of your neighborhood or area also experience the issue described in your complaint? y/n/Don't Know
If yes:
Is the issue affecting 500 or more households? Y/n/Don't Know
Is there a neighboring area that is receiving better service than you? Y/n/Don't Know
If yes:
Name of the neighboring area?
City of the neighboring area
State of the neighboring area
Zip of the neighboring area
What is the advertised download speed of the internet plan you subscribe to
25MB or less
26-50MB
51-100 MB
101MB- 500
501 MB - 999MB
1GB or more
Don’t Know
Internet method
Wireless
Cable
Satellite
DSL
Fiber
Company name (your provider)
Relationship to Company
Current Customer
Former Customer
Prospective Customer
Other
Have you contacted your provider about this issue? y/n
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)
Age of Complaint Filer? (Drop Down)
Under 18
18-24
25-34
35-44
45-54
55-64
65 or older
Ethnicity? (Drop Down)
Hispanic or Latino
Not Hispanic or Latino
Race(Multi-Select) Select one or more:
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Primary language spoken at home? (Multi-select)
English
Spanish
Chinese
French
Tagalog
Vietnamese
German
Korean
Other
Total Household Income? (Drop Down)
0-$20,000
$20,001-60,000
$60,001 - $100,000
$100,001 - $150,000
$150,001+
Housing? (Drop Down)
Multi-Unit Building(Apartment or Condo)
Single Family Home(House, Mobile Home, Townhome)
Other
Subject
Description
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 | 2024-07-22 |