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pdfLifeline Program Safe Connections Act Survey
NOT YET APPROVED BY OMB
OMB 3060-0819
Est. time per response: 10 minutes
Approval Edition: Month, Year
Safe Connections Act Survey
The Safe Connections Act (SCA) survey is provided to gather information concerning the communications
needs of survivors of domestic violence, sexual assault, and similar crimes who are helped by your
organization. The survey is also aimed at evaluating the effectiveness of using the Lifeline program benefit for
survivors, as permitted under the SCA of 2022. Survivors are allowed to enter the Lifeline program for up to six
months under expanded eligibility options if they are experiencing financial hardship. This survey is voluntary.
Please complete this survey to the best of your knowledge.
SERVICE NEEDS OF SURVIVORS
1. Which of the following does your organization serve? (select all that apply) [MULTIPLE SELECTION allow respondent to select more than one response]
•
Domestic violence or dating violence survivors
•
Human trafficking or sex trafficking survivors
•
Sexual assault survivors
•
Child abuse survivors
•
Elder abuse survivors
•
Other
2. What types of areas do the survivors you serve usually come from? (select all that apply) [MULTIPLE
SELECTION - allow respondent to select more than one response]
a. Urban areas
b. Suburban areas
c. Rural areas
d. Tribal lands
e. Other remote areas
3. Based on your interactions with survivors, when survivors first make contact with your organization,
what percentage do NOT have access to any phones or mobile devices that, with a service plan, would
allow the survivor to reliably make voice calls? [PERCENTAGE BAR WITH OPTION TO CHOOSE “I
DON’T KNOW” INSTEAD]
I don’t know
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NOT YET APPROVED BY OMB
Lifeline Program Safe Connections Act Survey
OMB 3060-0819
Est. time per response: 10 minutes
Approval Edition: Month, Year
4. What percentage of survivors that you serve are concerned about affording voice or internet service?
[PERCENTAGE BAR WITH OPTION TO CHOOSE “I DON’T KNOW” INSTEAD]
I don’t know
5. When first meeting with the survivors you regularly serve, how often do they participate in programs
targeted at low-income households like SNAP or Medicaid? [SCALE – respondent may only choose one]
•
Never
•
Occasionally
•
Often
6. Does your organization support survivors who are minors (under the age of 18)? [YES/NO – allow
respondent to only choose one]
•
Yes
•
No
7. If your organization supports minors, do they have an adult who cares for them and who is also
seeking services? [SCALE – respondent may only choose one]
•
Yes
•
No
•
Sometimes
•
Not applicable
8. For what types of devices or services do the survivors you assist most need financial help obtaining?
[MULTIPLE CHOICE – respondent may only choose one]
•
Voice communications services
•
Broadband (Internet service)
•
Phone/mobile device
•
Other connected devices (for example, laptop computer or tablet)
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NOT YET APPROVED BY OMB
Lifeline Program Safe Connections Act Survey
OMB 3060-0819
Est. time per response: 10 minutes
Approval Edition: Month, Year
9. For the answer you chose to question #8, for whom does the survivor most often need that device or
service? [MULTIPLE CHOICE – respondent may only choose one]
•
Themselves only
•
Themselves and dependent children
•
Themselves and dependent elders
•
Themselves and other dependent family members
•
Not for themselves, but for someone in their care
10. Over the following timespan, MM/YY - MM/YY, how many survivors did your organization
support? [OPEN FIELD]
SAFE CONNECTIONS ACT (SCA) RELATED QUESTIONS
11. Before filling out this survey, were you aware of the SCA benefit? [YES/NO – allow respondent to only
choose one]
•
Yes
•
No
12. About what percentage of survivors seeking help from your organization does your organization
know have applied for the Lifeline benefit? [PERCENTAGE BAR WITH OPTION TO CHOOSE “I
DON’T KNOW” INSTEAD]
I don’t know
13. If survivors you serve apply for the Lifeline benefit rather than the SCA benefit while receiving
support from your organization, what is the most common reason why they are not applying for the SCA
benefit? (select all that apply) [MULTIPLE SELECTION - allow respondent to select more than one
response]
•
They have heard about Lifeline, but not the SCA
•
They do not realize that the SCA provides a larger benefit for voice-only service ($9.25) than the
Lifeline voice-only benefit ($5.25)
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NOT YET APPROVED BY OMB
Lifeline Program Safe Connections Act Survey
OMB 3060-0819
Est. time per response: 10 minutes
Approval Edition: Month, Year
•
The application process is more difficult for the SCA than Lifeline
•
They don’t have line separation documentation
•
They prefer the long-term benefit of Lifeline over the short-term (6 months) benefit of the SCA
•
Survivors prefer to apply for a broad service program instead of one targeted at survivors
•
They are already enrolled in Lifeline
•
Not applicable
14a. Does your organization advertise or make survivors aware of the SCA benefit? [YES/NO –
allow respondent to only choose one]
a. Yes
b. No
14b. [If respondent answers Yes] If Yes, how? (select all that apply) [MULTIPLE SELECTION - allow
respondent to select more than one response]
•
In person
•
In person during consultations
•
By phone, text message, or email
•
Through flyers or bulletins at organization locations or events
•
Through flyers or bulletins outside of organization locations or events on organization websites
15. Are you providing or partnering with another organization to provide survivors with free or
discounted communication devices? (select all that apply) [MULTIPLE SELECTION - allow respondent to
select more than one response]
•
We provide free phones
•
We provide other free communications devices (for example, tablet, laptop computer)
•
We provide discounted phones
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We provide other discounted communication devices (for example, tablet, laptop computer)
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None of the above
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NOT YET APPROVED BY OMB
Lifeline Program Safe Connections Act Survey
OMB 3060-0819
Est. time per response: 10 minutes
Approval Edition: Month, Year
16. Without the SCA or Lifeline benefits, what option would the survivors you serve most likely take?
[MULTIPLE CHOICE – respondent may only choose one]
a. Survivors would continue to purchase voice or internet service but may reduce spending in other
ways
b. Survivors would continue to purchase voice or internet service with the assistance of non-profit
organizations, other government programs, or family/friends
c. Survivors would continue to purchase voice or internet service but reduce the quality of service
d. Survivors would continue to purchase voice or internet service but not have service for some
short periods of time
e. Survivors would not be able to purchase voice or internet service for long periods of time
17a. Is the amount of the $9.25 monthly SCA benefit enough to make the service affordable for survivors
to get their own service? [YES/NO – allow respondent to only choose one]
•
Yes
•
No
17b. [If respondent answers No] If No, what would be a sufficient monthly benefit amount? [OPEN
FIELD]
18. Do the survivors you serve have sufficient Lifeline/SCA voice and Internet plans from which to
choose? [MULTIPLE CHOICE – respondent may only choose one]
•
Yes
•
No
•
I don’t know
19. Based on your experience, what percentage of SCA benefit applicants that were approved were able
to apply their benefits to their existing service provider? [PERCENTAGE BAR WITH OPTION TO
CHOOSE “I DON’T KNOW” INSTEAD]
I don’t know
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NOT YET APPROVED BY OMB
Lifeline Program Safe Connections Act Survey
OMB 3060-0819
Est. time per response: 10 minutes
Approval Edition: Month, Year
20. Do survivors receive enough notice about the end of the SCA benefit (which lasts up to 6 months)?
[MULTIPLE CHOICE – respondent may only choose one]
•
Yes
•
No
•
I don’t know
21. Under the SCA, are survivors able to obtain a line separation from their abusers without much
difficulty? [MULTIPLE CHOICE – respondent may only choose one]
•
Yes
•
No
•
I don’t know
22. Please share additional information that might help us implement the Lifeline benefit for survivors.
We are also interested in any stories you have about helping survivors seek support to stay connected. In
your response, please do not provide the name or any other identifiable information of a survivor,
abuser, or someone in the survivor’s or abuser’s care. [OPEN FIELD]
23. Please indicate what type of response you provided in the previous question. [MULTIPLE CHOICE –
respondent may only choose one]
a. Anecdote
b
Recommendation
c. Not applicable
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NOT YET APPROVED BY OMB
Lifeline Program Safe Connections Act Survey
OMB 3060-0819
Est. time per response: 10 minutes
Approval Edition: Month, Year
NOTICE
PAPERWORK REDUCTION ACT NOTICE: This collection of information stems from the
Commission’s authority under Section 254 of the Communications Act of 1934, as amended, 47
U.S.C. §254. Using this authority, the FCC has designated USAC as the permanent Lifeline
Administrator. The FCC has published rules detailing how consumers can qualify for Lifeline services
and what Lifeline services they may receive (47 CFR §54.400 et seq.). The data provided in response
to this information collection will be used by USAC to evaluate the effectiveness of the Safe
Connections Act program.
We have estimated that each response to this collection of information will take, on average, 0.167
hours. Our estimate includes the time to read and complete the form and review the form or response.
If you have any comments on this 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 (3060-0819), Washington, D.C. 20554. We also will accept your
comments via the Internet if you send them to [email protected]. Please DO NOT SEND
COMPLETED DATA COLLECTION 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 Office of Management and Budget (OMB) control number. This collection has been
assigned an OMB control number of 3060-0819.
The Commission is authorized under the Communications Act of 1934, as amended, to collect the
information we request in this form. We will use the information that you provide to assist in
evaluating the effectiveness of the Safe Connections Act program. If we believe there may be a
violation or potential violation of a statute or a Commission regulation, rule, or order, your form may
be referred to the Federal, state, or local agency responsible for investigating, prosecuting, enforcing,
or implementing the statute, rule, regulation, or order. In certain cases, the information in your form
may be disclosed to the Department of Justice, court, or other adjudicative body when (a) the
Commission; (b) any employee of the Commission; or (c) the United States government, is a party to
a proceeding before the body or has an interest in the proceeding.
The foregoing Notice is required by the Paperwork Reduction Act of 1995, P.L. No. 104-13, 44
U.S.C. § 3501, et seq.
PRIVACY ACT STATEMENT: The Privacy Act is a law that requires the Federal Communications
Commission (FCC) and the Universal Service Administrative Company (USAC) to explain why we
are asking individuals for personal information and what we are going to do with this information
after we collect it.
Authority: Section 254 of the Communications Act (47 U.S.C. § 254), as amended, 47 U.S.C. §254,
authorizes the FCC to operate the Lifeline program. Using this authority, the FCC has designated
USAC as the permanent Lifeline Administrator. The FCC has published rules detailing how
consumers can qualify for Lifeline services and what Lifeline services they may receive (47 CFR
§54.400 et seq.).
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NOT YET APPROVED BY OMB
Lifeline Program Safe Connections Act Survey
OMB 3060-0819
Est. time per response: 10 minutes
Approval Edition: Month, Year
Purpose: We are collecting this personal information so we can efficiently provide Lifeline services.
We access, maintain and use your personal information in the manner described in the Lifeline
System of Records Notice (SORN), FCC/WCB-1, which is available at
https://www.fcc.gov/managing-director/privacy-transparency/privacy-act-information#systems/.
Routine Uses: We may share the personal information you enter into this form with other parties for
specific purposes, such as: with contractors that help us operate the Lifeline program; with other
federal and state government agencies that help us determine survivors’ eligibility; with the
telecommunications companies that provide survivors Lifeline services; and with law enforcement
and other officials investigating potential violations of Lifeline rules.
A complete listing of the ways we may use your information is published in the Lifeline SORN
described in the “Purpose” paragraph of this statement.
Disclosure: You are not required to provide the information we are requesting.
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| File Type | application/pdf |
| File Title | Word Document |
| Author | Ellery Mathews |
| File Modified | 2024-12-11 |
| File Created | 2024-09-19 |