FCC Form 2000D Emergency or Public Safety Complaint

Form 2000D – Emergency or Public Safety 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: _________________________________________________________________

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

1. What is the name of the company that is the subject of your complaint? _________________________________________________________

2. If your complaint is about a radio or television station, please provide the following information:

1. Station call sign (e.g., “KDID,” “WZUF,” “KDIU-FM,” “WZUE-TV”): ________________

2. Radio station frequency (e.g., “1020” or “88.5”): ______ or TV channel (e.g., “13”): ______

3. Station location: City: ________________________ State: ____

3. If you are complaining about a cable or satellite operator (e.g., Comcast, Time Warner, DirecTV), please provide the following information:

1. Operator name: _________________________________________

2. Operator location: City: ________________________ State: ____

4. If this complaint is about (check one):

 Interference generated by a broadcaster or cable operator to emergency/public safety services or

devices

 Compliance with Emergency Alert System (EAS) requirements

Provide the following information:

1. Date of incident: (mm/dd/yyyy): ___/ ___/ ______/

2. Time of incident: _______  AM  PM

3. Description of incident: __________________________________________________________

_________________________________________________________________________________

Form 2000D – Emergency or Public Safety Complaint

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

5. If you are complaining about interference to emergency/public safety services or devices generated by a piece of equipment, provide the following information:

1. Manufacturer/importer: ____________________________________________

2. Address of manufacturer/importer: ______________________________________________

3. Model number(s) of equipment: ___________________________________

4. Retailer: ________________________________________________________

5. Retailer address: _____________________________________________________________

6. Description of incident: __________________________________________________________

_________________________________________________________________________________

6. If you are complaining about problems with a wireless or broadcast tower, provide the following information:

1. Owner of tower: ___________________________________________________

2. Address or approximate location of tower: _________________________________________

3. Description of problem: _________________________________________________________

________________________________________________________________________________

7. If you are complaining about problems with Enhanced 911 service quality or availability, provide the following information:

1. Name of telephone company, wireless carrier, or Voice over Internet Protocol (VoIP) service provider: _________________________________________________

2. Telephone number involved (including area code): (____) ____ - _______ Ext: _____

3. Account number (if different from telephone number): ________________________

4. Date of violation or problem (mm/dd/yyyy): ___/ ___/ ______/

5. Description of Problem: _________________________________________________________

_________________________________________________________________________________

8. If you are complaining about any other emergency/public safety matter, provide the details of your complaint, including date, times and nature of any conduct or activity complained of and identifying information for any companies, institutions or individuals involved:

   1. Date (mm/dd/yyyy): ___/ ___/ ______/ b. Time: _______  AM  PM

3. _____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

You may submit this form over the Internet at http://wwww.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).

Form 2000D – Emergency or Public Safety Complaint

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 emergency or public safety. 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 common carrier, the complaint is forwarded to the defendant carrier 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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December 2007