Copy responder link
Copy
Published
Sign in
Section 1 of 3
Utility Disconnections: Share Your Story
Utility companies claim that they don't disconnect us when the weather is bad. But we know that isn't true. Help us win utility disconnection protections by sharing your story of when you were disconnected and how you were impacted.

Please read all the questions on this form first before answering.

This form is monitored by the Leave The Heat On Collective
Zip Code
Question Type
Loading image…
Answer key
(0 points)
Loading...
Loading…
Have you had your utilities disconnected when is was really cold or really hot?
Question Type
Loading image…
Yes, cold
Yes, hot
Yes, both
During extreme weather event
Been disconnected at a different time
No
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
Loading…
What was disconnected?
Question Type
Loading image…
Electric
Gas
Both
Neither
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
Loading…
What is the name of your utility company?
Question Type
Loading image…
Answer key
(0 points)
Loading...
Loading…
Do you remember when your disconnection happened and how long were you disconnected?
Question Type
Loading image…
Answer key
(0 points)
Loading...
Loading…
How much did you owe at the time of disconnection?
Question Type
Loading image…
Less than $50
Between $50-100
Between $100-150
More than $150
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
Loading…
How were you impacted by the disconnection?
Question Type
Optional: We know that utility disconnections impact people in a lot of different ways, for example when utilities are shut off you may lose your groceries from your refrigerator, not be able to run important medical devices, have negative health impacts, have mental health impacts from the stress and worry, face potential eviction or involvement of CPS, have to forego other important expenses (groceries, medicine, etc). Tell us a little about what happened.
Loading image…
Answer key
(0 points)
Loading...
Loading…
Can we share your story?
Question Type
Loading image…
Anonymously on social media or with reporters
With legislators (anonymously)
With legislators (with my name)
I would be willing to be interviewed about my experience
I would be willing to talk with legislators about my experience
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
Loading…
Can we contact you?
Question Type
Loading image…
Send resources for bill pay assistance in your area
Add you to our email list about upcoming actions
Follow up about your story
NO, please don't contact me
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
Loading…
Name
Question Type
optional
Loading image…
Answer key
(0 points)
Loading...
Loading…
Email
Question Type
optional
Loading image…
Answer key
(0 points)
Loading...
Loading…
Phone
Question Type
optional
Loading image…
Answer key
(0 points)
Loading...
Loading…
Section 2 of 3
Optional Other Questions
These questions are all optional. Feel free to skip this section if you would prefer.
When you were facing disconnection,  did you reach out to your utility about assistance? What did they say/offer?
Question Type
Loading image…
Answer key
(0 points)
Loading...
Loading…
When you were facing disconnection,  did you reach out to community agencies or churches (like Community Action) for assistance? Were they able to help?
Question Type
Loading image…
Answer key
(0 points)
Loading...
Loading…
Have you chosen not to pay other important bills so that you can pay for electricity or water? Which bills did you defer?
Question Type
Loading image…
Answer key
(0 points)
Loading...
Loading…
How many times have you had your utilities disconnected?
Question Type
Loading image…
Answer key
(0 points)
Loading...
Loading…
Is there anything else that you want to share?
Question Type
Loading image…
Answer key
(0 points)
Loading...
Loading…
Section 3 of 3
Demographic Information
These questions are all optional.  Feel free to skip this section if you would prefer.
Please indicate your household income.
Question Type
Loading image…
$0 - $30,000
$30,001 - $60,000
$60,001 - $90,000
$90,001 - $120,000
$120,000 or more
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
Loading…
Do you consider yourself part of a vulnerable household?  (Check all that apply.)
Question Type
Loading image…
Seniors (65+)
Children under 5
Person with disability or chronic disease
Fixed or limited income
Other:
Add option
…
Answer key
(0 points)
Loading...
Loading…
How many people are in your household
Question Type
Loading image…
1 - 2
3 - 5
5 - 7
8+
Add option
or
add "Other"
…
Answer key
(0 points)
Loading...
Loading…
Do you support protections that prevent utility shutoffs during extreme heat or cold weather?
Question Type
Loading image…
Support
Neutral
Oppose
Strongly Oppose
Other:
Add option
…
Answer key
(0 points)
Loading...
Loading…
Link to Sheets
Insights
Total points distribution
Loading...
Loading responses…
Zip Code
Copy chart
No responses yet for this question.
Have you had your utilities disconnected when is was really cold or really hot?
Copy chart
No responses yet for this question.
What was disconnected?
Copy chart
No responses yet for this question.
What is the name of your utility company?
Copy chart
No responses yet for this question.
Do you remember when your disconnection happened and how long were you disconnected?
Copy chart
No responses yet for this question.
How much did you owe at the time of disconnection?
Copy chart
No responses yet for this question.
How were you impacted by the disconnection?
No responses yet for this question.
Can we share your story?
Copy chart
No responses yet for this question.
Can we contact you?
Copy chart
No responses yet for this question.
Name
Copy chart
No responses yet for this question.
Email
Copy chart
No responses yet for this question.
Phone
Copy chart
No responses yet for this question.
Optional Other Questions
When you were facing disconnection,  did you reach out to your utility about assistance? What did they say/offer?
No responses yet for this question.
When you were facing disconnection,  did you reach out to community agencies or churches (like Community Action) for assistance? Were they able to help?
No responses yet for this question.
Have you chosen not to pay other important bills so that you can pay for electricity or water? Which bills did you defer?
No responses yet for this question.
How many times have you had your utilities disconnected?
No responses yet for this question.
Is there anything else that you want to share?
No responses yet for this question.
Demographic Information
Please indicate your household income.
Copy chart
No responses yet for this question.
Do you consider yourself part of a vulnerable household?  (Check all that apply.)
Copy chart
No responses yet for this question.
How many people are in your household
Copy chart
No responses yet for this question.
Do you support protections that prevent utility shutoffs during extreme heat or cold weather?
Copy chart
No responses yet for this question.
Settings
Responses
Manage how responses are collected and protected
Presentation
Manage how the form and responses are presented
Defaults
Form defaults
Settings applied to this form and new forms
Question defaults
Settings applied to all new questions
.