FCC Form 2000C Disability Access Complaint

Not Approved by OMB

3060-0874

Estimated time per response: 30 minutes

Form 2000C – Disability Access Complaint

Consumer’s Information:

First Name: _______________________ Last Name: ____________________________

Company Name: ______________________________________________________________________

(Complete only if you are filing this complaint on behalf of a company or an organization.)

Street Address or Post Office Box Number: _________________________________________

City: ___________________ State: ___ Zip Code: _______ - _____

Telephone Number (Residential or Business): (____) ____ - _______  Ext: _____

E-mail Address: _________________________________________________________________

Are you filing information on behalf of another party, such as client, parent, spouse or roommate?

___ Yes ___ No If yes, complete items a through g.

1. Your relationship with the party: ______________________________________

2. The party’s first name: ____________________________________

3. The party’s last name: ____________________________________

4. The party’s daytime phone number: (____) ____ - _______  Ext: _________

5. The party’s street address or post office box number: ________________________________

6. City ___________________ State: ___ Zip Code: _________________

7. E-mail address: __________________________________

IMPORTANT: Please indicate the preferred format or method of response to the complaint by the Commission and defendant:  Letter  Facsimile (fax)  Telephone Voice  TRS (designate form of TRS and appropriate contact information) ________________________________  TTY  Internet E-mail

 ASCII Text  Audio-Cassette Recording  Braille

* * * Answer each question that applies to your specific complaint * * *

1. Check the appropriate box for your type of complaint:

• Telecommunications Relay Service (TRS) (for example., TTY-based, IP Relay, CapTel, IP CapTel

Speech-to-Speech, Video Relay Service (VRS))

 Accessibility of emergency information on television

• Closed Captioning on television (from a television station or subscription TV provider, for example,

cable, fiber optic or satellite)

• Closed Captioning of television programs streamed or downloaded from the Internet (for example, to your computer, tablet, smartphone, television, video game console, or other Internet-enabled device)

Form 2000C – Disability Access Complaint

* * * Answer each question that applies to your specific complaint * * *

 Wireless telephone equipment or service (includes hearing aid compatibility and other

accessibility issues)

 Wireline telephone equipment or service (includes hearing aid compatibility and other

accessibility issues)

 Video Description (audio narrated description of a TV program’s key visual elements)

2. Provide the name, address and telephone number (if known) of the company(s) involved in your complaint:

Name: ________________________________________________________________

City: ___________________ State: ___ Zip Code: ___________________
Telephone number: (____) ____ - _______

3. If your complaint is about accessibility of telecommunications services or equipment, provide the make and

model number of the equipment or device that this complaint is about:

_____________________________________________________________________________________

4. If your complaint is about closed captioning or emergency information on television,

provide the date (mm/dd/yyyy) ___/ ___/ ______/ and time _______  AM  PM

and any details of when the event or action you are complaining about occurred: ____________________

_____________________________________________________________________________________

5. If your complaint is about access to emergency information on television, provide the following information:

a. Television station call sign and network name (if applicable), or channel name

(for example, “WZUF, CBC,” “WZUE-TV,” “Sportingchannel West”):_____________________

b. Channel (for example, “13”): _____________

c. Station or subscription TV provider system location: City ____________________________

County ________________________ State: ____

d. Date(s) and time(s) of emergency: ___/ ___/ ______/ and time _______  AM  PM

e. Detailed description of the emergency (for example, flood, hurricane, tornado, etc., as well as the

areas in which the emergency occurred): ______________________________________________

_______________________________________________________________________________

6. If your complaint is about video description or closed captioning on television, provide the following:

a. Television station call sign and network name (if applicable), or channel name (for example,

“WZUF, CBC,” “WZUE-TV,” “Sportingchannel West”): _________________________

b. Channel (for example, “13”): _____________

c. Station or subscription TV provider system location: City __________________________

County ________________________ State: ____

d. If you pay to receive television programming, type of subscription service (for example, cable,

satellite): _________________________________

e. If you pay to receive television programming, name of company to whom you subscribe:

_________________________________

f. Name of program(s) involved: _____________________________________________________

7. If your complaint is about closed captioning of television programs streamed or downloaded from
the Internet, provide the following information:

a. Information about the program viewed (for example, "Orange Blossoms, Season 3, Episode 6"):

______________________________________________________________________________

Form 2000C – Disability Access Complaint

* * * Answer each question that applies to your specific complaint * * *

b. Name, address, website, or e-mail address of the program distributor, provider, and/or owner (for example, "WZUF-CBC.com," "WZUE-TV.com," "SportingchannelWest.com," "TV&MoviesOnline"):_____________________________________________________________

_____________________________________________________________________________

c. Information about the device or software used to view the program (for example, manufacturer,

model number, name of video player software or application): _____________________________

______________________________________________________________________________

d. Date (month/day/year) ___/____/____and time _______ (a.m. / p.m.) the program was viewed.

8. Briefly describe your complaint and include the resolution you are seeking. If applicable, provide a full

description of the telecommunications equipment or customer premises equipment (CPE) and/or the telecommunications service about which the complaint is made, and the date or dates on which the complainant either purchased, acquired or used, or attempted to purchase, acquire or use the telecommunications equipment, CPE or telecommunications service about which the complaint is being made. ____________________________________________________________________________

__________________________________________________________________________________

__________________________________________________________________________________

You may submit this form over the Internet at http://www.fcc.gov/cgb/complaints.html, by e-mail to fccinfo@fcc.gov, by fax to 1-866-418-0232, or by postal mail to:

Federal Communications Commission
Consumer & Governmental Affairs Bureau
Consumer Complaints
445 12th Street, SW
Washington, D.C. 20554

In addition, you may submit your complaint over the telephone by calling 1-888-CALL-FCC or 1-888-TELL-FCC (TTY). If you choose to submit your complaint over the telephone, an FCC customer service representative will fill out an electronic version of the form for you during your conversation. If you have any questions, feel free to contact the FCC at 1-888-CALL-FCC or 1-888-TELL-FCC (TTY).

FCC NOTICE REQUIRED BY THE PAPERWORK REDUCTION ACT AND THE PRIVACY ACT

The Federal Communications Commission is authorized under the Communications Act of 1934, as amended, to collect the personal information that we request in this form. This form is used for complaints that involve disability access. The public reporting for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the required data, and completing and reviewing the collection of information. If you have any comments on this burden 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 (3060-0874), Washington, DC 20554. We will also accept your comments regarding the Paperwork Reduction Act aspects of this collection via the Internet if you send them to PRA@fcc.gov. PLEASE DO NOT SEND YOUR COMPLETED 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 OMB control number or if we fail to provide you with this notice. This collection has been assigned an OMB control number of 3060-0874.

In addition, the information that consumers provide when filling out FCC Form 2000 is covered by the system of records notice, FCC/CGB-1, Informal Complaints and Inquiries File (Broadcast, Common Carrier, and Wireless Telecommunications Bureau Radio Services). The Commission is authorized to request this information from consumers under 47 U.S.C. 206, 208, 301, 303, 309(e), 312, 362, 364, 386, 507, and 51; and 47 CFR 1.711 et seq.

Under this system of records notice, FCC/CGB-1, the FCC may disclose information that consumers provide as follows: when a record in this system involves a complaint against a company, the complaint is forwarded to the defendant who must, within a prescribed time frame, either satisfy the complaint or explain to the Commission and the complainant its failure to do so; where there is an indication of a violation or potential violation of a statute, regulation, rule, or order, records from this system may be referred to the appropriate Federal, state, or local agency responsible for investigating or prosecuting a violation or for enforcing or implementing the statute, rule, regulation, or order; a record from this system may be disclosed to a Federal agency, in response to its request, in connection with the hiring or retention of an employee, the issuance of a security clearance, the reporting of an investigation of an employee, the letting of a contract, or the issuance of a license, grant or other benefit; a record on an individual in this system of records may be disclosed, where pertinent, in any legal proceeding to which the Commission is a party before a court or administrative body; a record from this system of records may be disclosed to the Department of Justice or in a proceeding before a court or adjudicative body when: (a) the United States, the Commission, a component of the Commission, or, when represented by the government, an employee of the Commission is a party to litigation or anticipated litigation or has an interest in such litigation, and (b) the Commission determines that the disclosure is relevant or necessary to the litigation; a record on an individual in this system of records may be disclosed to a Congressional office in response to an inquiry the individual has made to the Congressional office; a record from this system of records may be disclosed to GSA and NARA for the purpose of records management inspections conducted under authority of 44 U.S.C. 2904 and 2906. Such disclosure shall not be used to make a determination about individuals.

In each of these cases, the FCC will determine whether disclosure of the information in this system of records notice is compatible with the purpose for which the records were collected. Furthermore, information in this system of records notice is available for public inspection after redaction of information that could identify the complainant or correspondent, i.e., name, address and/or telephone number.

THE FOREGOING NOTICE IS REQUIRED BY THE PAPERWORK REDUCTION ACT OF 1995, PUBLIC LAW 104-13, OCTOBER 1, 1995, 44 U.S.C. SECTION 3507 AND THE PRIVACY ACT OF 1974, PUBLIC LAW 93-579, DECEMBER 31, 1974, 5 U.S.C. SECTION 552a(e)(3).

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