Access & Functional Needs Self-Identification Survey

Access & Functional Needs Self-Identification Survey
Survey should take only 5 minutes to complete.

*Denotes a required field.

* Customer Name:

* First Name:

M. Initial:

* Last Name:

Suffix:

* SCE Service Account Number

* Billing Address:

* Number:

* Street:

Unit/Apt:

* City:

* State:

* Zip Code:

Mobile Phone:
Must be a 10-digit phone number, including area code.

Home Phone:
Must be a 10-digit phone number, including area code.

Email Address:

* Did you receive a survey in the mail?

Yes

Do any of the following apply to you or a member of your household?
Please check all that apply.

Disability

Blind or Low Vision

Deaf or Hard of Hearing

Mobility Disability (e.g., use a walker, wheelchair, mobility scooter, etc.)

Other Disability (e.g., Intellectual or Developmental Disability (IDD), Mental, Cognitive, such as autism, Down Syndrome, Post Traumatic Stress, dementia, or Alzheimer’s, etc.)

If applicable, does accommodating the disability require electricity?

Yes

How many people in your household identify with any of the above disabilities?

No one in my home experiences any of the above under General or Disability

Language Preference

Customer Consent: Demographics and Marketing

Would you like SCE to send you communications about the availability of programs and services that would benefit your household, based on the demographic information you provided in this survey?

Yes

Privacy

The information provided through this survey is only for internal use at SCE. However, if requested, SCE may be required to share some of this information with the California Public Utilities Commission (CPUC). Additionally, data may be shared with relevant emergency response personnel and other public safety partners during or in preparation for PSPS outages or other emergencies. For additional information about how SCE manages your personal information, please click on this link: https://www.sce.com/privacy