Form FEMA Form 90-147 FEMA Form 90-147 Registration Intake Survey

R EGISTRATION INTAKE SURVEY OMB Control No: 1660-0036

(May 24, 2007)

Hello, I’m calling from FEMA, the Federal Emergency Management Agency. My name is <your name>. May I please speak with ____________________(applicant name)?

If no: Is there a better time tonight when I may call back? Thank you for your time and have a nice evening.

[Code attempt as “Call Back”, add a general comment with a time to call back and select a new Survey.]

If yes: You placed a call to one of our offices _____ days ago to register for disaster assistance related to ________________ (name of disaster). Do you remember speaking with (HSR name)?

(Applicant name), we’re looking for ways to improve our service based upon your opinions. Would you volunteer to take 10-15 minutes to answer some questions right now?

If yes: Good. The following questions have been approved by the Office of Management and Budget under number 1660-0036. Please be assured that your responses will in no way affect the outcome of your application for FEMA assistance.

If no, document the Attempt Field as “Decline”: Okay. Thank you for your time and have a nice evening.

KEY RATING QUESTION
All right, (Applicant’s name), we’ll start with a very general question about the service you received from FEMA.
Question		Response Options
Overall, how would you rate the information and support you’ve received from FEMA since the disaster occurred? Would you say it‘s been………………………….. (READ list) (If “Below average” or “Poor”, go to Q. 1a, otherwise skip to Q.2.)		Excellent Good Satisfactory Below average, or Poor (DO NOT read) Don’t know / No opinion
1a. In what way was the information and support you received [below average / poor]? (DO NOT read list)		Did not receive enough / any financial Assistance Poor Customer Service (Attitude, Respect, Interest, etc.) Application process too complicated Information inconsistent or wrong, programs not explained clearly Dissatisfaction with Inspection Difficulty REACHING FEMA Insurance related issues (has coverage so no assistance, etc.) Took too long to complete application Other

RI REPRESENTATIVE QUALITY
Question	Responses
Thinking only about your initial telephone call to FEMA to apply for disaster assistance, how would you rate the way the Representative you spoke with handled your call? Would you say the [HSR name/representative] was ……………………. (READ list) If (Below Average or Poor) go to Q. 2a, otherwise skip to Q.2b (attribute series).	Excellent Good Satisfactory Below Average, or Poor (DO NOT read) Don’t know / No opinion
2a. In what way was your call [below average / poor?) (DO NOT read list. Mark all that apply.)	Didn’t receive any / enough ASSISTANCE Rep had poor ATTITUDE Language Barrier Didn’t EXPLAIN programs clearly or could not answer questions Didn’t seem INTERESTED in helping me Didn’t take time to LISTEN to me Took TOO LONG to complete application Rep made errors on my application or the call (disconnected me, etc.) Didn’t treat me with RESPECT Other (Specify)

RI REPRESENTATIVE – ATTRIBUTE SERIES
You may have already answered some of these questions; but, just to make sure I understand your opinions, I’m going to ask you some specific questions about the Representative you spoke with.
Question	Response Options
2b: How would you rate [HSR name] on showing a genuine interest in your situation? (Read list AS NEEDED)	Excellent Good Average Below average, or Poor (DO NOT read) Don’t know / No opinion
2c.on taking the time to listen to the details of your situation? (Read list AS NEEDED)	Excellent Good Average Below average, or Poor (DO NOT read) Don’t know / No opinion
2e.on treating you with respect? (Read list AS NEEDED)	Excellent Good Average Below average, or Poor (DO NOT read) Don’t know / No opinion
2f. How would you rate [HSR name/ the representative] overall attitude during your call? ? Would you say it was…. (READ list) (If “Below average” / “Poor”, go to Q.2g., otherwise skip to Q.2h.)	Excellent Good Satisfactory Below average, or Poor (DO NOT read) Don’t know / No opinion
2g. How was [HSR name/ the representative’s] attitude [ Below Average / Poor]? (DO NOT read list)	CONDESCENDING, Disrespectful IMPATIENT; did not Listen RUDE/Discourteous Not interested, no compassion, no empathy Other

RI REPRESENTATIVE – EXPLAINING PROGRAMS
Question	Response Options
2h. How would you rate [HSR name/the representative] on clearly explaining the disaster assistance programs and services available to you? Would you say…. (Read list) If “below average / poor” go to Q.2i, otherwise skip to Q.3.	Excellent Good Satisfactory Below Average, or Poor (DO NOT read) Don’t know / No opinion
2i. What programs and services was [HSR name/the representative] unable to explain (DO NOT read List)	Language Barrier Transportation Rental/Hotel/Motel Programs not explained or not accurately Personal Property Access Road/Bridge/Driveway, DEBRIS Removal Other

POST-DISASTER COMMUNICATION
Now, I’d like to ask you some general questions about FEMA.
Question		Response Options
3. After the disaster, how did you hear about FEMA? Probe Once: How else did you hear about FEMA?		Newspaper Television Radio FEMA Employees Community Groups	Friends / Relatives Flyers Church Other (Put specific response in comments box)
3a. How would you rate the effectiveness of that communications in helping you get the Information you need? Would you say it is……………….. (READ list)		Excellent Good Satisfactory Below Average, or Poor (DO NOT read) Don’t know / No opinion
3b. How was the information [below average / poor]? (DO NOT read List)		The information did not ACCURATELY represent the services provided by FEMA The information was CONFUSING Information was INSUFFICIENT or Too Late Did not receive any / enough Assistance Had to SEEK out information on my own Other (Put specific response in comments box)

CALL CENTER ACCESS
Question		Response Options
When you called the 800 number to register, did you have any difficulty reaching a FEMA representative? If “YES” go to Q.4a. ,otherwise skip to Q.5.		Yes No
4a. What difficulty did you have? (DO NOT READ. Select ONE ONLY)		BUSY, Recording to Call Back Too LONG to answer or on Hold too Long TRANSFERRED too many times Phone Line / computer system problems Other (Put specific response in comments box)

EASE OF APPLYING
Question		Response Options
5. How would you rate FEMA on making it easy to apply for disaster assistance? Would you say it was… (READ list) If “below average/poor”, go to Q5a, otherwise skip to Q6		Excellent Good Satisfactory Below Average, or Poor (DO NOT read) Don’t know / No opinion
5a. In what way was it not easy?		Too COMPLICATED Took too much TIME Other (Put specific response in comments box)

INSPECTION TIMEFRAME
Question	Response Options
Now I’d like you to think about the Inspection FEMA conducted to assess your damages.
I see you had multiple inspections. Which one would you like to be surveyed about? 6a. How many days after your call did FEMA conduct the inspection? (ENTER EXACT NUMBER OF DAYS (0 is ok). DO NOT ACCEPT A RANGE)	[______]Initial inspection [______]Second inspection [______]
6b. How would you rate the amount of time between your registration and the inspection? Would you say the amount of time was……. (READ list)	Excellent Good Satisfactory Below Average, or Poor (DO NOT read) Don’t know / No opinion
6c. Overall, how satisfied are you with the inspection FEMA conducted? (READ list) If “less than satisfied ” / “not at all satisfied”, go to Q.6d, otherwise skip to Q.7	Extremely satisfied Very satisfied Satisfied Less than satisfied, or Not at all satisfied (DO NOT read) Don’t know / No opinion
6d. Why were you dissatisfied with the inspection? (DO NOT read List)	Not qualified, no financial assistance or not enough Poor Customer Service Did not look at all my damages Did not answer my questions Did not come at scheduled time Did not take enough time, did not listen to me Other (Put specific response in comments box)

REPUTATION IN COMMUNITY
Question		Response Options
Next, I’d like you to think about the image FEMA has in your community.
7. Based on what you have seen, read, and heard, as well as your personal opinion, how would you rate FEMA’s overall reputation in your community? Would you say it is …….. (READ list) (If below average or poor, go to Q7a, otherwise skip to Q8.)		Excellent Good Satisfactory Below Average, or Poor (DO NOT read) Don’t know / No opinion
7a. What do you think the reason would be for [below average / poor]? (DO NOT read list, check all that apply)		Poor Customer Service (Attitude, Respect) Application process too COMPLICATED No CONSISTENCY in amount awarded FEMA didn’t seem INTERESTED in helping Took too LONG to get assistance Disaster assistance information MIS-COMMUNICATED Not enough MONEY awarded Was told I did not QUALIFY for assistance Too much RED TAPE to get assistance Lack of Awareness of FEMA in the Community (no presence, no information) Other (Put specific response in comments box)

AGENCY REFERRALS
Question		Response Options
Did the FEMA Representative refer you to other Agencies that may also be able to provide you with assistance?		Yes (Go to 8a) No (Skip to 8b) Don’t Remember (Skip to 8b)
8a. Which Agencies were you referred to? (Check highlighted agencies that respondent can recall. Blue indicates NEMIS referral.) (Check if respondent does not recall all of the NEMIS referrals or requests additional referrals, then go to question 8B.)		REFERRED AGENCIES (HIGHLIGHTED AGENCIES WERE REFERRED)	RECALL REFERRAL
		SMALL BUSINESS ADMINISTRATION
		AMERICAN RED CROSS
		FARM SERVICES AGENCY
		LOCAL UNEMPLOYMENT Assistance
		INTERNAL REVENUE
		INSURANCE COMPANY
		OTHER

8b. Based on your application, you may have been referred to (read highlighted referrals that applicant did not identify above). Would you like me to give you the information so you can contact them when you have an opportunity?	Yes (Give contact info from NEMIS) No (Go to Q. 9)
If respondent has not contacted insurance company, explain importance of filing claim and supplying FEMA with a letter of denial or settlement information.

SUGGESTIONS TO IMPROVE
Question		Response Options
For this next question, FEMA is interested in getting your opinion on what they could do to improve our service.
9. What suggestions would you like to pass on to FEMA? (Specify PROBE one time: “What else?”)		Open-ended: Type in applicant response. _________________________________________________________________________________________________________________

CUSTOM QUESTIONS: for special usage to benefit planning, program changes, future enhancements, etc.

CUSTOM QUESTIONS – Registration Intake Phone Survey or Helpline Phone Survey Re: On-Line Registration Attempt
Question	Response Options
This question is about the On-Line Internet Registration available at the FEMA.gov website. This allows you to enter your Registration over the internet and is available 24 hours a day 7 days a week.
CQ IAC-Reg#1. Did you personally, attempt to do your Registration over the Internet? If no go to Question CQ IAC-Reg#1a. If yes go to Question CQ IAC-Reg#1b. If Don’t remember, go to Next Question	Yes No (DO NOT read) Don’t remember
CQ IAC-Reg#1a. What were your reasons for not using the internet? (DO NOT Read List, listen and mark all that apply)	Don’t have a COMPUTER Don’t have Internet ACCESS Computer DAMAGED Limited computer SKILLS SECURITY Concerns WEBSITE was not accessible Wanted to TALK to FEMA DIDN’T KNOW I could register on-line UTILITIES were out could not use computer Other (Specify)
CQ IAC-Reg#1b. Why were you unable to complete your registration over the Internet? (Do not read list; listen and mark all that apply.)	Did not have compatible BROWSER Unable to NAVIGATE FEMA.gov GENERAL instructions not clear SPECIFIC instructions for entering data not clear Too COMPLICATED / difficult to use Not confident so ALSO registered over the phone Unable to ACCESS the site of page Difficulty with characters on SECURITY SCREEN Response time too slow Could not complete due to TECHNICAL problems HELP DESK could not answer to technical questions Took TOO LONG Other (Specify)

CUSTOM QUESTIONS – Registration Intake Phone Survey or Helpline Phone Survey Re: Internet Inquiry or Update
Question		Response Options
This question is about the Internet Individual Assistance Center on the FEMA.gov website where you may view your account 24 hours a day 7 days a week. This includes checking your eligibility and inspection status, correspondence or making minor changes to insurance or contact information.
CQ IAC-Inq # 1. Did you try to use the FEMA.gov website to check on your application? If no, go to CQ IAC-Inq#1a If yes go to Question CQ IAC-Inq #1b If don’t remember, Go to Next Question	Yes No (DO NOT read) Don’t remember
CQ IAC-Inq#1a What were your reasons for not using the internet?	Don’t have a computer Don’t have internet access Computer damaged Limited computer skills Security concerns Website was not accessible Wanted to talk to FEMA Didn’t know about the on-line service Utilities were out; could not use computer
CQ IAC-Inq #1b. Why were you unable to use the Individual Assistance Center Website to inquire into your case?	Did not have compatible browser Unable to navigate FEMA.gov Instructions were not clear Could not complete due to technical problems Helpdesk could not answer technical questions Not confident changes were made / called Helpline to verify Unable to access the site or page Difficulty with logon, pin, password Response time too slow Too complicated / difficult to use Information I wanted was not available Took too long to view / edit my information Other (Specify)

CUSTOM QUESTIONS – Auto Dialer Feature
Another feature FEMA uses to keep you informed is an auto dialer which calls you to let you know that FEMA has received your fax, your letter or your mail was returned. (It may also used to let you know when we have sent a letter so that you can be expecting it in the mail.)
Question	Response Options
(Ask CQAD#1 only if the information is not available electronically). CQAD#1. Did you receive a recorded message from FEMA stating your correspondence or fax was received or mail was returned? (Or a message explaining you will be receiving a letter from FEMA in the mail?) If No or Do Not Remember, go to “Next Question” at the bottom of the screen. If yes, go to CQAD#1a	Yes No Do not Remember (DO NOT read list)
(Ask CQAD#1a only if the information is not available electronically). CQAD#1a. What document did the recording refer to? (DO NOT read list. Mark all that apply.) Continue to CQAD#1b if 4-6 selected; Otherwise, continue to CQAD#1c:	1) Fax or Correspondence received at FEMA 2) App’s Mail Returned to FEMA 3) FEMA Letter to App - X 4) FEMA Letter to App - Y 5) FEMA Letter to App – Z 6) EFT 7) Registration received 8) Inspection Scheduled 6) Do not Remember 7) Other (specify)
If 3) or 4) or 5) from CQAD#1a, ask CQAD#1b. Did you receive the automated message before you received your letter in the mail?	Yes On the same Day No Do not remember
CQAD#1c. How many times did you receive the same message?	0 number of times 1 2 3 4 5 More than 5
CQAD#1ca. Was that ____ (number) just right, okay or too many?	Just right Okay Too many

CUSTOM QUESTIONS – Auto Dialer Feature	continued
CQAD#1d How did you feel about the time of day you received the recording. Was it convenient for you? If no, go to CQAD #1da , if Yes or Don’t Know, go to CQAD#1	Yes No Don’t know/No opinion
CQAD#1da What time of day did you receive the recording?	_______ cst on a ____day
CQAD#1e. How helpful was that recording? (Read list.) (If Somewhat helpful, Not very helpful or Not at all helpful, go to CQAD#1ea)	Extremely helpful Very helpful Somewhat helpful Not very helpful Not at all helpful (do not read) Don’t know/No opinion
CQAD#1ea. In what way? (DO NOT read list. Mark all that apply.)	Confusing Not sure which document the recording referred to Did not understand what I was to do next Sound was not clear Received the same message over and over again Message came too late, I already knew about the information Had already called the HL Had to call the HL (record Yes in CQAD#1f) Other (specify)
For all responses from CQAD#1e CQAD#1f. Did you need to call the FEMA Helpline after you heard the recording? If yes, go to CQAD#1fa	Yes No Do not Remember
CQAD#1fa. What help did you need? (DO NOT read list. Mark all that apply.)	Clarification of the auto dialer message To hear the auto dialer message repeated To change my address, phone number, etc. To ask what to do next To appeal (or ask how to appeal) To ask what my funds covered To ask what the letter I received referred to Other (specify)

CUSTOM QUESTIONS – Auto Dialer Feature	continued
If CQAD#1f is Yes: CQAD#1g. Was the HL representative knowledgeable about the recorded message you received?	Yes No Do not Remember
CQAD#1h. What suggestions do you have to improve this recorded message feature? [If any, enter the suggestion]

CUSTOM QUESTIONS – Automated Information System (IVR) 5-24-07
Question	Response Options
Another service FEMA has is an automated information system to let applicants check the status of their application over their phone.
(Ask CQIVR#1 only if the information is not available electronically). CQIVR#1. Have you used this automated method to check the status of your case? (Do not READ list) If No or Do not Remember, go to Next Question. If yes to CQIVR#2	Yes No Do not Remember
CQIVR#2. Were the instructions on the automated system easy to understand? (Do not READ list) If No, go to CQIVR#2a. If Yes or Do not Remember, go to CQIVR#3.	Yes No Do not Remember
CQIVR#2a. What made it difficult? (Do not READ list. Check all that apply)	Terminology was confusing Did not know what it meant Did not know what to do next Could not hear due to hearing issues Could not hear due to phone issues Could not hear due to recording not clear Language or dialect issues Other
CQIVR#3. How helpful was the automated system in providing you the information you needed? (READ list) If Somewhat, Not very, or Not at all Helpful, ask CQIVR#3a. Otherwise, go to CQIVR#5.	Extremely Helpful Very Helpful Somewhat Helpful Not very Helpful Not at all Helpful (DO NOT read) Don’t know / No opinion

CUSTOM QUESTIONS – Automated Information System (IVR)	continued
Question	Response Options
CQIVR #3a. Tell me a little about that experience. (Do not Read the list. Check all that apply.)	Confusing terminology Could not navigate Could not skip through Did not understand the status Instructions not clear Instructions too long Had to contact Helpline (record Yes in CQIVR#4) Had to punch too many numbers Had to start over Needed additional information No way to repeat the needed instruction No way to go back to the beginning Not confident the status was accurate Poor sound quality Other (record specific reason)
For all responses: CQIVR#4. After you used the automated system, did you need to speak to a FEMA Helpline Representative for additional information or clarification? If yes, go to CQIVR#4a If No or Do not Remember, go to CQIVR#5.	Yes No Tried but was not able to Reach the HL Do not Remember
CQIVR#4a: At the beginning of the automated message, you were prompted to select specific numbers. After you made your menu selections, was your call transferred correctly and were you able to speak to a Helpline agent? If No, go to CQIVR#4b If Yes, go to CQIVR#4c	Yes No Do not Remember
CQIVR#4b: What happened to your call?	Got the wrong selection Had to start over Could not skip through the prompts Had to wait for the Spanish script to end Spoke too fast Other

CUSTOM QUESTIONS – Automated Information System (IVR)	continued
Question	Response Options
CQIVR#4c. What additional information did you need? (Do not Read the list. Check all that apply.)	To be sure the automated message was correct To understand the status To ask how to appeal To ask what to do next To ask what my funds covered To ask when my funds would be received To ask if the funds would come by check or EFT To ask what the letter I received referred to To ask which of my documents had been received To ask if my documents had been received Other (specify)
CQIVR#4d. Was the HL representative knowledgeable about the message you heard on the automated information system?	Yes No Do not Remember
CQIVR#5: If you needed to, would you use the automated system again?	Yes No
CQIVR#6. What suggestions do you have to improve the automated system? [If any, enter the suggestion]

SPECIAL NEEDS CUSTOM QUESTION – Through “yes” response to NEMIS RI question about Support Loss for Special Needs: "Did you, your spouse, or any dependents have help or support doing things like walking, seeing, hearing, or taking care of yourself before the disaster and have you lost that help or support because of the disaster?” A “yes” response indicates the applicant had help or support and have lost that help or support because of the disaster including the following: Mobility, Hearing/Speech, Cognitive/Mental Health, Vision an Other. OR Data provided by Special Needs Coordinator when disaster specific needs are identified; such as, over age 60 or Community Relations, DRC, ISC, EOC or another Agency identifies a need, or the Long Term Recovery Committee has exhausted all resources.			Rev 5-24-07
We are calling Applicants who indicated they have additional needs and who have been contacted by a FEMA Special Needs Caseworker (from the JFO) to see if assistance is available:
QUESTION		RESPONSE
CQSN#1	Has a FEMA Special Needs Caseworker given you a courtesy call about your needs for support after the disaster? If Yes: What was the name of the FEMA person who contacted you?______ (If not do remember, leave blank and skip CQSN#2) If Do Not Remember: Skip to the next Custom Question	Yes No Do not Remember (Use of JFO database will provide this answer. Skip to CQSN#1a)
CQSN#2	Overall, how would you rate the way the Special Needs Caseworker handled that call? Would you say ____/the disaster worker was…	Excellent Good Satisfactory Below Average Poor Do not know/no opinion
CQSN#2a	If Below Average or Poor: In what way was the contact [below average/poor]? (NOTE: Do not read the list, listen and mark all that appl.)	Didn’t receive financial assistance Didn’t receive enough financial assistance Process was too complicated Took too long to receive assistance Rep didn’t seem interested in helping me Rep didn’t take time to listen to me Rep didn’t treat me with respect Rep had poor attitude Rep didn’t explain programs clearly Could not contact the Rep to ask additional questions Other:

SPECIAL NEEDS CUSTOM QUESTION		Page 2
QUESTION		RESPONSE
CQSN#3	How would you rate _____/ (the Special Needs Caseworker) on clearly explaining the disaster assistance programs and services available to you? Would you say…	Excellent Good Satisfactory Below Average Poor Do not know/no opinion
CQSN#3a	If Below Average or Poor: What programs and services were ___/ (the Special Needs Caseworker) not able to explain? (NOTE: Do not read the list, listen and mark all that apply.)	Medical Dental Funeral Housing Assistance, specify: ____ Other Needs Assistance, specify: ____ Other:
CQSN#4	During this contact, were you referred to another agency (or agencies) for assistance? If no (This concludes the SN questions, go to next Custom Question) If yes, go to CQSN#5	Yes Which one(s)? ______, _______, _______ (Use of JFO database will provide this answer. Skip to CQSN#5) No
CQSN#5	Did you contact that agency (those agencies)? If yes, go to CQSN#6 If any other response, go to next Custom Question	Yes No Tried but was not able Decided not to Do not Remember

SPECIAL NEEDS CUSTOM QUESTION			Page 3
QUESTION		RESPONSE
CQSN#6	For the 1st Agency: How would you rate the overall assistance provided by ________ (agency)?	Excellent Good Satisfactory Below Average Poor Do not know/no opinion
CQSN#6a	If Below Average or Poor: In what way was the assistance [below average or poor]?	Didn’t receive any assistance Didn’t receive enough assistance Process was too complicated Took too long to receive assistance Rep was not knowledgeable Rep had poor customer service Other:
CQSN#7	For the 2nd Agency you were referred to: How would you rate the overall assistance provided by ________ (agency)? (Use multiple referral questions as needed.)	Excellent Good Satisfactory Below Average Poor Do not know/no opinion
CQSN#7a	If Below Average or Poor: In what way was the assistance [below average or poor]?	Didn’t receive any assistance Didn’t receive enough assistance Process was too complicated Took too long to receive assistance Rep was not knowledgeable Rep had poor customer service Other:

SPECIAL NEEDS CUSTOM QUESTION			Page 4
QUESTION		RESPONSE
CQSN#8	For the 3rd Agency: How would you rate the overall assistance provided by ________ (agency)?	Excellent Good Satisfactory Below Average Poor Do not know/no opinion
CQSN#8a	If Below Average or Poor: In what way was the assistance [below average or poor]?	Didn’t receive any assistance Didn’t receive enough assistance Process was too complicated Took too long to receive assistance Rep was not knowledgeable Rep had poor customer service Other:

CUSTOM QUESTIONS- CENTRALIZED LOCATION
Question	Response Options
CQCL-1 If FEMA were to provide internet access at a centralized location, how likely would you be to go to that location to use the internet and other services provided? (READ list)	Extremely likely Very likely Somewhat likely Not very likely, or Not at all likely (DO NOT read) Don’t know / No opinion

CQCL-2. Next, I’d like to get your opinion on which types of services you feel would be helpful to you if you went to a centralized location. Using a rating scale of Not Important, Somewhat Important or Very Important, please tell me the level of importance you place on each of the following services: (READ list)
	Type of service	Not important	Somewhat Important	Very Important
CQCLa. CQCLb. CQCLc. CQCLd. CQCLe. CQCLf. CQCLg CQCLh CGCLi CQCLj. CQCLk	access to disaster assistance program information apply for disaster assistance over the internet learn about documentation you’ll need to apply look up the status of your case make minor corrections to your application access a telephone have E-Mail capability have Faxing capability make copies of needed documents access to a printer What else do you think FEMA should provide at that location?

CUSTOM QUESTIONS – Disaster Recovery Center 5-24-07 modification
Question	Response Options
CQDRC#1 (was CQ#3). Following the disaster, did you have an opportunity to visit FEMA’s Disaster Recovery Center? (If “YES”, go to CQDRC#2, otherwise skip to the next Custom Question.)	Yes No Would have gone but there were none located in my area (DO NOT read) Do Not Remember
CQDRC#2 What was the reason you visited the Recovery Center? (Do not read list, check all that apply)	To Register To get general information Check on my FEMA Case Check on my ONA Case Deliver Paperwork for FEMA/ONA Fix the Problems on my Case Visit SBA Get Hazard Mitigation Information Visit other Agencies. Which ones?___ (ARC, Unemployment, etc) Other
CQDRC#3 Were your needs met during that visit? (If no or not completely, go to CQDRC#4)	Yes No Not Completely
CQDRC#4 Why not?	No phones to register No internet to register Computers were not set up Needed to furnish additional information Proof of Ownership Proof of Identity Receipts or Estimates Agency I needed was not available that day: Which agency? ____ (ARC, Unemployment, Mitigation, etc.) Center was too busy Center was too noisy No privacy FEMA Rep could not answer my questions SBA Rep could not answer my questions Other

CUSTOM QUESTIONS – Disaster Recovery Center, continued 5-24-07 modification
CQDRC #5 (was #3a). Overall, how would you rate the quality of service you received at that Center? Would you say it was… (READ list) (If Excellent, Good or Satisfactory, go to CQDRC#6) (If “Below average” / “Poor”, go to CQ#7)	Excellent Good Satisfactory Below average, or Poor (DO NOT read) Don’t know / No opinion
CQDRC#6 If Excellent, Good, Satisfactory: Could you tell me a little about that experience? (If any remarks, enter text)
CQDRC #7. Why do you feel that way? (DO NOT read list, Mark all that Apply)	Difficulty finding DRC Hours of Operation were not convenient Computer System was down Staff had poor attitude Staff didn’t treat me with respect Staff gave no explanation of programs Probe for clarity and Which Programs ? _____ Staff tried but could not explain the programs Probe for clarity and Which Programs? ____ Staff didn’t take time to listen to me Staff didn’t seem interested in helping me Took too long to get assistance at the DRC Had to return numerous times to provide documentation My documents were lost by the DRC Other (Specify)
CQDRC #8 What was the location of the Center?	_______ (specify)
CQDRC #9 What suggestions do you have to improve the service at the Recovery Center? If any, enter the text

CUSTOM QUESTIONS – FUTURE USE
Question		Response Options
CQ1. (DO NOT read list)		Yes No Don’t know / No opinion

CUSTOM QUESTIONS – FUTURE USE
Question		Response Options
CQ2. (DO NOT read list) .		True False Don’t know / No opinion

CUSTOM QUESTIONS – FUTURE USE
Question		Response Options
C34. (READ list)		Extremely likely Very likely Somewhat likely Not very likely, or Not at all likely (DO NOT read) Don’t know / No opinion

CUSTOM QUESTIONS – FUTURE USE
Question		Response Options
CQ4. (READ list)		Excellent Good Satisfactory Below average, or Poor (DO NOT read) Don’t know / No opinion

PERMISSION QUESTION
Question		Response Options
All right, (Applicant’s Name), I have only one more question for you.
10. FEMA is very interested in the quality of service we provide you. May we call you at a later date to ask you additional questions?		Yes No
CLOSING
If “yes,” Great! Thank you very much for your patience and cooperation in answering our questions. Have a good evening.
If “No,” I understand. Thank you very much for taking the time to talk with me. Have a good evening.

Paperwork Reduction Act Notice: Public reporting burden for this survey is estimated to be an average of 15 minutes per response. The burden includes the total time for answering the questionnaire. Although voluntary, you are not required to respond to this collection of information unless a valid OMB control number is presented to you during the interview. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Paperwork Reduction Act Project (1660-0036), Information Collections Management, Federal Emergency Management Agency, Department of Homeland Security, 500 C St. SW, Washington, DC 20472.

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Fema Form 90-147