Telecommunications Break Report Form
Report telecom service outages with detailed information to assist rapid resolution.
Full Name
*
First Name
Last Name
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Location of Affected Service
*
Type of Service Affected
*
Internet
Landline Phone
Mobile Service
Television
Other
Is the outage a total or partial loss of service?
*
Total loss of service
Partial/intermittent loss
When did the outage start?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Estimated Duration of Outage (in hours)
*
Number of Impacted Users
*
Describe the outage and any error messages observed
*
Troubleshooting steps already attempted
Preferred Callback Method
Phone Call
Email
Text Message
Additional Notes or Comments
Submit Report
Should be Empty: