Priority Support Needs Register
Identify customers needing priority service: medical equipment, accessibility, and contacts.
5 questions · 2 pages · about 3 minutes to answer · fully editable after you start
Outages are inconvenient for most customers and dangerous for some: powered medical equipment, mobility constraints, communication needs. This register form asks for consent first – anyone who does not give it leaves before sharing a single detail – and then lets customers (or carers) record the account holder and address, the situations and equipment in the household, and an optional alternative contact, so priority-service obligations are met with data rather than discovered in crisis. Replace [phone number] with the number people can call to register by phone or ask questions.
Offer it at signup and annually; the register is both a regulatory requirement in many markets and, more simply, how a utility avoids its worst possible headline.
Template preview
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Page 1 of 2
Before you start
This form adds your household to our priority support register, so we can warn you before planned interruptions and put you first during outages. We keep what you tell us only for priority support.
If you would rather register by phone, or want to know more first, call us on [phone number].
Q1.Do you consent to us keeping this information for priority support?*
Answering “No, I do not consent” or “I need more information first” ends the survey here.
- Yes, I consent
- No, I do not consent
- I need more information first
Page 2 of 2
Your household
Q2.The account holder and the service address*
Q3.Which of these apply in your household? Tick all that apply.*
- Medical equipment that needs power
- Mobility or accessibility needs
- Communication needs (hearing, sight, language)
- Young children, or an older person living alone
- Other…
Q4.Briefly describe the support that would matter to you during an interruption.*
Q5.Someone else we may contact, such as a relative or carer (optional)
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