Access & Functional Needs Self-Identification Survey

Account Holder Customer Name

First Name Please provide a first name.

Last Name Please provide a last name.

SCE Service Account Number What's this?

Please enter a valid account number. Your service account number starts with an “8” and consists of 10 numerical digits.

Contact Information

Service Address 1 Please enter your service address

Service Address 2

City City is required.

State State is required.

ZIP Code ZIP is required and must be 5 digits.

Home Phone Number

Mobile Number

Email Address Please provide a valid email address.

Did you receive a survey in the mail?

Yes

No

Please make a selection.

Do any of the following apply to you or a member of your household?

Please check all that apply.

General

Rely on medical equipment that requires electricity (e.g., CPAP machine, feeding tubes, respirator, motorized wheelchair/scooter, lift, or hospital bed, etc.)

Require heating and/or cooling for body temperature regulation?

Rely on assistive technology (e.g., screen reader, tablet for communication, specialized meal device, etc.)

Require refrigeration for medical purposes (e.g., medication, insulin, breastmilk, immunotherapy, etc.)

Do not have access to a vehicle and/or require accessible transportation

Unable to leave home without difficulty

Older adult (65+)

Disability

Blind or Low Vision

Deaf or Hard of Hearing

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

1

2

3+

Language Preference

Does your household require American Sign Language (ASL)?

Yes

No

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

No

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: sce.com/privacy.