111 Contact Code Application Form

Instructions for completing this form:

  1. Fill in Parts A, B and C of the form.
  2. Complete the declaration in Part D of the form.
  3. Submit the completed form.

Complete this application form if you want us to consider you (or someone you are applying on behalf of) to be covered by the 111 Contact Code.

This form can only be completed by one of the following people:

  • a customer (the account holder);
  • a person who is listed as an authority on the customer’s account; or
  • the customer or person listed as an authority on the customer’s account on behalf of someone who occupies the premises where the phone service is supplied.













    Part A: Personal Details


    Yes (fill out 3a)No (Go to Q2)


    Yes (fill out 3a and 3b)No *You must be added as an authority to the customer’s account before you make this application

    3a. Details of customer





    MrMsMrsMissDrOther, please specify







    3b. Details of person listed as an authority on the customer’s account

    Please only fill out this section if you are not the customer





    MrMsMrsMissDrOther, please specify






    Home phoneMobileMailEmail


    I am applying to be covered by the 111 Contact Code (Go to Part B)I am applying on behalf of someone else (fill out 5a)

    5a. Details of person who wants to be covered by the 111 Contact Code

    Please only fill out this section if you are applying on behalf of someone else





    MrMsMrsMissDrOther, please specify

    How to complete Part B

    1. Read Guidance Note 1.
    2. Complete Q6 and Q7

    Part B: Information on the person at particular risk


    HealthSafetyDisability

    PermanentTemporary

    If you selected ‘Temporary’, what is the estimated period of time the category of particular risk will apply to the person?

    How to complete Part C

    1. Read Guidance Note 2.
    2. Complete Q8.

    Part C: Supporting information


    Sufficient evidence to support that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service (fill in 8a)Details of a nominated person we can contact to verify that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service (fill in 8b and 8c)

    Please describe the supporting evidence you are providing:



    8b. Details of nominated person

    Details of a nominated person we can contact to verify that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service









    8c. Declaration regarding nominated person

    Please note that if you are making this application on behalf of someone else, before completing this declaration, you must have received permission from that person to authorise us to contact the nominated person

    • I authorise Telesmart Ltd to contact (Full name of nominated person) for the purposes of verifying that I (or the person I am applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service.


    How to complete Part D

    1. Read Guidance Note 3.
    2. Complete the declaration.

    Part D: General declaration

    • I acknowledge and declare that, to the best of my knowledge, the information given in this form is correct;
    • I acknowledge and declare that :
      (please insert your name here, or the person you are applying on behalf of)

      • is (or will become) at particular risk of requiring the 111 emergency service; and
      • does not have a means to contact the 111 emergency service at the premises (such as access to a mobile phone) that can be operated for a continuous 8-hour period in the event of a power failure;
    • I understand that the information I have provided in this form will be stored with Telesmart Ltd;
    • I understand that the information I have provided in this form may be shared with relevant third parties for the purposes of providing and managing my service.


    Guidance Notes

    GUIDANCE NOTE 1

    For a person to be covered by the 111 Contact Code they must be ‘at particular risk of requiring the 111 emergency service’.

    Part B asks for information that will allow us to know that the person who is applying to be covered by the 111 Contact Code is ‘at particular risk of requiring the 111 emergency service’. The person could be ‘at particular risk’ now, or sometime in the near future, and they may be at risk on a temporary or permanent basis.

    Q What does ‘at particular risk of requiring the 111 emergency service’ mean?

    A person who is “at particular risk of requiring the 111 emergency service” means a person who is more likely than other people to require the 111 emergency service because of a specific circumstance applicable to that consumer.

    The following scenarios illustrate some situations where a person may be considered ‘at particular risk’ under the 111 Contact Code.

    Scenario one

    Mary and Joe are pensioners living together. These days Joe is unsteady on his feet. He has fallen over a couple of times recently. Mary is active but spends most of her time at home looking after Joe. Mary is worried that the next time Joe falls he might seriously injure himself.

    Scenario two

    Fatima has type 2 diabetes and is in the early stages of dementia. Fatima needs to take medication every day to manage her conditions.

    Scenario three

    Jennifer’s father has moved back into the family home. He’s been verbally and physically abusive to family members in the past and Jennifer is worried that it might happen again.

    Scenario four

    Tane is booked in to have both knees replaced. He lives alone and is worried about complications or a fall and needing to access the 111 emergency service during recovery over the next three months.

    Q What do the ‘Health’, ‘Safety’ and ‘Disability’ categories in Question 6 mean?

    This question asks you to select which of three categories (health, safety or disability) most closely relates to the specific circumstance you (or the person you are applying on behalf of) has that means you (or the person you are applying on behalf of) is at particular risk of requiring the 111 emergency service.

    If you tick the ‘health’ category, this means the specific circumstance that makes you (or the person you are applying on behalf of) at particular risk of requiring the 111 emergency service is related to health. For example, it is a known medical condition.

    An example of a specific circumstance that may mean you tick the ‘safety’ category is family violence. An example of a specific circumstance that may mean you tick the ‘disability’ category is sensory impairment, intellectual impairment or physical impairment.

    Q Do I have to be ‘at particular risk’ now, or could it be sometime in the future?

    A person may not be ‘at particular risk’ now, but they know they will become ‘at particular risk’ sometime in the near future. For example, a person who has a planned surgical operation.

    Q How can a person be ‘at particular risk’ on a temporary or permanent basis?

    A person may be ‘at particular risk’ because they have suffered a physical injury, but the person expects to recover from this injury after a certain period of time. In these circumstances, the person is only ‘at particular risk’ on a temporary basis.

    An example of a person who may be ‘at particular risk’ on a permanent basis is a person who has congenital blindness and will not recover.

    Question 7 asks you to tell us whether the specific circumstance that makes you (or the person you are applying on behalf of) ‘at particular risk’ is on a temporary or permanent basis.


    GUIDANCE NOTE 2

    Part C asks for information to support the answers given to Q6 and Q7 in Part B.

    One of the following must be provided:

    1. sufficient evidence to support that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service; or
    2. the details of a nominated person we can contact to verify that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service.

    Q Who can be a ‘nominated person’?

    A nominated person must be someone who, by virtue of their occupation, is competent to give an opinion on whether you (or the person you are applying on behalf of) is at particular risk of requiring the 111 emergency service.

    For example, if the ‘health’ or ‘disability’ category has been ticked in response to Q6, then a health practitioner (such as a GP) could be a nominated person. If the ‘safety’ category has been ticked, then a police officer, a currently registered social worker, a lawyer (with a current practicing certificate), or a family court judge could be a nominated person.

    We recommend that before you make your application to us, you (or the person you are applying on behalf of) first contact the nominated person to discuss the application.

    Q If I don’t provide the details of a nominated person, what sort of evidence must be provided?

    It must be sufficient information to show that you (or the person you are applying on behalf of) is (or will become) at particular risk of requiring the 111 emergency service.

    Examples of evidence that may be sufficient include:


    GUIDANCE NOTE 3

    Part D asks you to make some declarations regarding the content you have provided in the application, and to acknowledge that you understand what we (the provider) may do with the information you have provided in the application.

    One of the declarations asks you to declare that the person who wants to be covered by the 111 Contact Code:

    • is (or will become) at particular risk of requiring the 111 emergency service (information on what this means is provided in Guidance Note 1); and
    • does not have a means to contact the 111 emergency service that can be operated at the premises for a continuous 8-hour period in the event of a power failure”.

    Q What is the 111 emergency service?

    The 111 emergency service includes the ambulance service, police service and fire and emergency service.

    Q What does ‘a means to contact the 111 emergency service that can be operated at the premises for a continuous 8hour period in the event of power failure’ mean?

    It means that the person has a way of contacting the 111 emergency service at the premises where they live.

    The ‘means’ a person uses to contact the 111 emergency service must be able to work for a continuous (ie non-stop) 8-hour period if used as instructed.

    A person will have a way of contacting the 111 emergency service if:

    • the premises where they live is receiving a copper landline service (because this service will continue to work in a power cut);
    • the person has unrestricted access to a mobile phone and the premises where they live has adequate mobil phone network coverage; or
    • the person has an uninterruptable power supply to maintain a means for contacting the 111 emergency service in the event of a power failure (eg a battery back-up).

    GENERAL GUIDANCE

    What is the 111 Contact Code?

    The purpose of the 111 Contact Code is to ensure that consumers who are at particular risk of requiring the 111 emergency service, and do not have a means for contacting the 111 emergency service, have reasonable access (or persons on their behalf do) to an appropriate means (eg, a mobile phone) to contact the 111 emergency service in the event of a power failure.

    If you have a dispute about your (or your telecommunication company’s) rights and obligations under the 111 Contact Code, you have a right for that dispute to be referred to an industry dispute resolution scheme to resolve. A consumer’s right to take a dispute under the 111 Contact Code to an industry dispute resolution scheme is protected under the Telecommunications Act 2001 (sections 241-245). Currently, the relevant industry dispute resolution scheme is the Telecommunications Dispute Resolution Scheme.

    The 111 Contact Code is administered by the Commerce Commission. More information on the 111 Contact Code, and a copy of the 111 Contact Code, is available on the Commerce Commission’s website here:

    https://comcom.govt.nz/regulated-industries/telecommunications/projects/commission-111-contact-code

    What is the Telecommunications Dispute Resolution Scheme?

    The Telecommunications Dispute Resolution Scheme is a free, independent service to help consumers with complaints about their telecommunications provider. A dispute between a consumer and a telecommunications company about their rights and obligations under the 111 Contact Code may be referred to this Scheme.

    For more information on the Telecommunications Dispute Resolution Scheme you can contact us at 0800 835 376 and we will refer to where to find more information, or you can read more about the Scheme and how to contact them on their website here: https://www.tdr.org.nz/about-tdr/all-about-tdr.

    Who should I contact if I have any questions about this form?

    Please contact us at 0800 835 376 if you have any questions about the form, or the 111 Contact Code more generally.

    Alternatively, you can contact the Commerce Commission at contact@comcom.govt.nz, or phone the Commission’s Enquiries team on 0800 943 600.