| Item 1: Action Requested |
Enter "A" to request an initial TSP assignment
for a service |
| Item 2: Date
Service Required |
Enter month, day, and year (MM/DD/YYYY). |
| Item 3: Service
User Service ID |
Enter the unique identifier used to recognize this
service. This identifier can be any unique combination of letters
and numbers used to identify the service in your records. |
| Item 4: TSP
Authorization Code |
Leave blank. |
| Item 5: Service
Profile |
The service profile defines the user's level of support
to the portion of the telecommunications service that the user owns
and operates, such as customer premises equipment and customer
premises wiring. The service profile is used to determine
the priority level a service is required to receive. |
| Item 6: Restoration Priority Information |
Complete ONLY if requesting a Restoration priority. |
| Item 6a: Category
|
- Determine the category under which the service qualifies for priority treatment using
the table below:
- Enter the letter of the category (A, B, C, or
D) in item 6a.
|
| Item 6b: Criteria |
- From the information below, identify the category
that was selected in 6a.
- Under the category, identify the number that
defines the NS/EP function the service supports
- Enter the number (0, 1, 2, 3, 4, 5, 6, 7,
8 or 9) in item 6b.
|
| Item 6c: Restoration Priority Requested |
Read the following instructions and use the
Table for Determining
Priority Levels to determine the appropriate priority
level. Enter this item in 6c.
- Identify the category you listed in Item 6a.
- Identify all the service profile elements that
you listed in Item 5.
- Identify the priority level that corresponds
to the category and service profile elements you identified
in items 6a and 5, respectively. Note that you must satisfy all service profile elements identified for a corresponding
priority level to qualify for that priority level.
- Enter that priority level (5, 4, 3, 2, or 1)
or a lower priority level in Item 6c. If your service does not
meet all the elements/details for a given priority level, but,
nevertheless, you consider that a higher priority level is warranted,
enter that priority level in Item 6c and provide your justification
in Item 8.
|
| Item
6d: Prime Vendor (Company Name) |
Enter the name of the prime service vendor
authorized to provide the TSP service. |
Item 7: Provisioning Priority Information
|
Complete ONLY if requesting a Provisioning priority. |
| Item 7a: Provisioning Priority Information |
- Determine the category under which the service qualifies for priority treatment using
the table below:
- Enter the letter of the category (A, B, C, D,
or E) in Item 7a.
|
| Item 7b: Provisioning
Criteria |
- From the information below, identify the category
that was selected in 7a.
- Under the category, identify the number that
defines the NS/EP function the service supports. If this
is an Emergency service, identify the appropriate number from
the criteria listed under Category E.
- Enter the number (0, 1, 2, 3, 4, 5, 6, 7,
8 or 9) in item 7b.
|
Item
7c: Provisioning Priority Requested:
Enter the appropriate provisioning priority level based on the
chart below
and instructions to the right. |
For an emergency provisioning request, enter
"E" in Item 7c. (Note: To qualify under the Emergency NS/EP
category, the service must support service profile elements
A3 and B2.) For Essential provisionings, read the following
instructions and use the Table
for Determining Priority Levels to determine the appropriate
priority level to enter in Item 7c.
- Identify the category you listed in Item 7a.
- Identify the service profile elements that you listed in Item
5.
- Identify the priority level that corresponds to the category
and service profile elements you identified in Items 7a and
5, respectively. Note that you must satisfy all service
profile elements identified for a corresponding priority level
to qualify for that priority level.
- Enter the priority level (5, 4, 3, 2, or 1) in Item 7c. If
your service does not meet all the elements/ details for a given
priority level, but, nevertheless, you consider that a higher
priority level is warranted, enter that priority level in Item
7c and provide your justification in Item 8.
|
Item
7d and 7e: Invocation Official's Name and
Title
| Enter the invocation official's name and title. This
information must be on file with the OPT or the provisioning priority
cannot be assigned.
|
| Item 7f: Telephone Number
| Enter the commercial telephone number of the invocation official.
|
| Item 7g: Has the invocation
official authorized this action?
| Enter Y (yes) or N (no).
|
| Item 7h: Service Locations
| Enter the specific street address, including building, floor,
room number, etc. and provide a POC name and telephone number for
each end service location.
|
| Item 7i: Prime Vendor
POC for Provisioning
| Enter the name and telephone number and company of the prime vendor
point of contact.
|
| Item 8: Supplemental Information
| Provide: (1) circuit specification(s) for provisioning priority
only; (2) justification for requested priority level if higher than
qualified for; or (3) sponsor justification for priority level change
in Item 12e, Recommended Disposition.
|
Item 9: Service User
An entry other than "A" requires Federal Government sponsorship
(see Item 12).
| Enter "A" if the service is for any Federal government organization.
Enter "B" for any State government organization.
Enter "C" for any county, city, town, or other local government
organization.
Enter "D" for any private sector organization or private U.S. citizen.
Enter "E" for any foreign government or foreign government organization.
Enter "F" for other.
Enter "G" for U.S. military. |
| Item 10: Service User
Organization (Department/Agency and/or FIPS
Code) |
Federal agencies should enter the appropriate four-digit code
for their organization, as indicated in Federal Information Processing
Standard (FIPS) Publication
95. All others should enter the organization name and the name of
the State (e.g., Nelson County Hospital, Minnesota). |
| Item 11: Service User
Point of Contact |
Enter information regarding the person or office who is responsible
for this service and can provide information about this service. |
| Item 11a: Name and Title |
Enter the service user point of contact name and title. |
| Item 11b: Organization
(Department/Agency and/or FIPS
Code) |
Same as Item 10. |
| Item 11c - 11e: Mailing
Address, Telephone Number and Facsimile Number |
Enter complete mailing address and phone and fax numbers. |
| Item 11f: 24-Hour Telephone
Number |
Enter a telephone number at which the point of contact is reachable
24-hours a day. |
| Item 11g: E-mail Address |
Enter E-mail address if applicable. |
| Item 11h: Signature
and Date |
The form must be signed and dated or it will be returned unprocessed.
By signing the form, the requestor confirms the service is an NS/EP
service. |