Intake Assessment

Facility Broadband Assessment: FWA Focus

Estimated time: ~5-7 minutes. Please complete one form per physical facility. If you manage multiple facilities, answer the portfolio questions at the end.

1. Facility Name

Physical Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Contact Person-Name, Role, Phone, Email

First name

Last name

Role

Phone

Email

4. Facility Type

Facility Size

Approx Square Feet

On-Site Staff (Typical)

Peak Concurrent Users

Current Internet Service

ISP Name (e.g. Comcast)

Advertised Speed down/up (e.g. 200/20mps)

Monthly Costs

Please select

Facility uses static IP(s) or dedicated circuits

Connection used for mission-critical services (telehealth, POS, security)

7. Current Performance Issues

8. Discounts, Subsidies, or special pricing in place

9. On-site technical readiness for fixed wireless

Roof Access available for antenna/installation

Nearby Mounting pole or structure

No easy exterior mounting; indoor options only

Power and backhaul

Reliable on-site power

Generator/backup power

10. Line of sight and obstruction notes

11. Power and networking on-site

On-site managed switch or network closet

VLANs or segmented network for guest/critical services

Existing Wi-Fi APs (brand/model optional)

Other

If Other, please provide notes here

12. Required or desired service levels

13. Budget Constraints

14. Additional facility relationships

15. Permission for site survey

Yes-we may schedule a brief roof/exterior survey

Not today; follow-up required

16. Notes and attachments

File upload