Two Generic Clearance Surveys

FY 2010 Work Incentives Planning and Assistance (WIPA) Survey

GENERAL INTRODUCTION
Hello, my name is (interviewer first and last name). I work for (insert contractor name) and I’m
calling today on behalf of Social Security. Social Security recently sent you a letter explaining
that someone would be calling to ask your opinion about the information and services you
received from (insert site name) under a special program to help people with disabilities who
want to work. This program is called Work Incentives Planning and Assistance.
Under this special program, counselors called Community Work Incentives Coordinators are
helping Social Security by getting important information to people about what happens to their
benefits when they work. The counselors also explain the special rules called “work incentives”
that are available to help people go to work.
All of your answers will be kept private and won’t be used for any other purpose. We won’t ask
for any personal information as part of the survey, just for your opinions of the service you
received. The survey will take less than 20 minutes to complete. May we begin now?

1.

Do you remember talking to a counselor from (insert site name) about how work and
earnings affect your benefits and what work incentives might be available to help you?
(Do not read responses. Enter one response.)
a. Yes (Skip to Q3.)
b. No
(If question 1 is answered “no,” probe to encourage recall with question 2.)

2.

Social Security records show that you received help from a counselor working for
(insert site name). The counselor doesn’t work for Social Security but knows all their
rules so they can help people who get Social Security benefits who might want to work.
The counselor’s job is to explain to you what happens to your cash benefits, medical
insurance and other types of assistance if you work and earn money. The counselor
also explains the special rules called “work incentives” that can help you go to work.
Do you remember talking with someone about this?
(Do not read responses. Enter one response.)
a.
b.

Yes
No (Skip to end.)

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3.

How did you learn about the services provided by (insert site name) under the Work
Incentives Planning and Assistance program?
(Do not read responses. Select all that apply.)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

4.

Was told about it by a social worker, lawyer or other professional
Someone from the site named above or another organization (Department of Labor,
Vocational Rehabilitation, etc.) gave a talk
Saw it in the Ticket to Work information Social Security sent me
Was referred by the Employment Network (EN) or Maximus
Was told about it by a Social Security employee
Saw it on Social Security’s Internet website or in a Social Security office
Saw/heard an ad or sign somewhere else; e.g., on the radio, in a local clinic
Was told about it by a friend or relative
Other (Record response ____________________________________________)
Don’t remember

When you first contacted (insert site name), how satisfied were you with how soon a
counselor was available to talk to you? Were you:
(Read rating scale. Enter one response.)
a.
b.
c.
d.
e.

Very satisfied
(Skip to Q6.)
Somewhat satisfied
(Skip to Q6.)
Somewhat dissatisfied, or
Very dissatisfied
No opinion (Do not read.) (Skip to Q6.)

5.

Why were you dissatisfied with how soon a counselor was available?
(Record response ____________________________________________)

6.

Did you talk to the counselor face-to-face, on the telephone or both?
(Do not read responses. Enter one response.)
a.
b.
c.
d.

Face-to-face only
Telephone only (Skip to Q14.)
Both
Don’t remember (Skip to Q21.)

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7.

Where did you usually meet with the counselor? Did you usually meet:
(Read responses; stop as soon as a response is chosen. Enter one response.)
a.
b.
c.
d.

8.

Considering things like transportation, parking and the distance from your home, how
would you rate the convenience of the location where you usually met with the
counselor? Was it:
(Read rating scale. Enter one response.)
a.
b.
c.
d.
e.
f.
g.

9.

At their office
At some other location outside your home, or
In your home
(Skip to Q14.)
Don’t remember (Skip to Q14.)

Excellent
(Skip to Q10.)
Very good
(Skip to Q10.)
Good
(Skip to Q10.)
Fair
Poor, or
Very poor
No opinion (Do not read.) (Skip to Q10.)

Why did you say the convenience of the location was (insert response from Q8)?
(Record response ______________________________________________)

10. Thinking about things like the availability of automatic doors, elevators and
wheelchair ramps, how accessible was the building where you usually met? Was it:
(Read rating scale. Enter one response.)
a.
b.
c.
d.
e.
f.
g.

Excellent
(Skip to Q12.)
Very good
(Skip to Q12.)
Good
(Skip to Q12.)
Fair
Poor, or
Very poor
No opinion (Do not read.) (Skip to Q12.)

11. Why did you say the accessibility of the building was (insert response from Q10)?

4
(Record response ________________________________________________)

12. How would you rate the privacy at your meeting place? Was it:
(Read rating scale. Enter one response.)
a.
b.
c.
d.
e.
f.
g.

Excellent
Very good
Good
Fair
Poor, or
Very poor
No opinion
to Q14.)

(If Q6 = face-to-face only, skip to Q21. If Q6 = both, skip to Q14.)
(If Q6 = face-to-face only, skip to Q21. If Q6 = both, skip to Q14.)
(If Q6 = face-to-face only, skip to Q21. If Q6 = both, skip to Q14.)

(Do not read.) (If Q6 = face-to-face only, skip to Q21. If Q6 = both, skip

13. Why did you say privacy was (insert response from Q12)?
(Record response _________________________________________________)
(If Q6 = face-to-face only, skip to Q21. If Q6 = both, continue with Q14.)

14. Did you ever try to call the counselor?
(Do not read responses. Enter one response.)
a.
b.
c.

Yes
No
(Skip to Q21.)
Don’t remember (Skip to Q21.)

15. How satisfied were you with the time it usually took you to get through to the counselor
on the telephone? Were you:
(Read rating scale. Enter one response.)
a.
b.
c.
d.
e.

Very satisfied
(Skip to Q17.)
Somewhat satisfied
(Skip to Q17.)
Somewhat dissatisfied, or
Very dissatisfied
No opinion (Do not read.) (Skip to Q17.)

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16. Why were you dissatisfied? (Record response ________________________________)

17. Did you ever leave a message asking the counselor to call you back?
(Do not read responses. Enter one response.)
a.
b.
c.

Yes
No
(Skip to Q21.)
Don’t remember (Skip to Q21.)

18. How soon did the counselor usually call you back? Was it usually the:
(Read responses. Enter one response.)
a.
b.
c.
d.
e.
f.

The same day
The next work day
Later, but still within about a week
Over a week later, or
Were you never called back
Don’t remember (Do not read.) (Skip to Q21.)

19. How satisfied were you with the time it took the counselor to return your calls? Were
you:
(Read rating scale. Enter one response.)
a.
b.
c.
d.
e.

Very satisfied
(Skip to Q21.)
Somewhat satisfied
(Skip to Q21.)
Somewhat dissatisfied, or
Very dissatisfied
No opinion (Do not read.) (Skip to Q21.)

20. Why were you dissatisfied? (Record response _____________________________)

6
21. Now I’d like to ask you a few questions about the counselors that you spoke with.
Were you helped by only one or more than one counselor?
(Do not read responses. Enter one response.)
a.
b.
c.

Only one
More than one
Don’t remember

22. Thinking about all the counselors who may have helped you, how would you rate their
courtesy? Was it:
(Read rating scale. Enter one response.)
a.
b.
c.
d.
e.
f.
g.

Excellent
Very good
Good
Fair
Poor, or
Very poor
No opinion (Do not read.)

23. How would you rate the helpfulness of the counselor? Was it:
(Read rating scale. Enter one response.)
a.
b.
c.
d.
e.
f.
g.

Excellent
Very good
Good
Fair
Poor, or
Very poor
No opinion (Do not read.)

26. Would you rate the amount of time the counselor spent with you as:
(Read rating scale. Enter one response.)
a.
b.
c.

Excellent
Very good
Good

7
d.
e.
f.
g.

Fair
Poor, or
Very poor
No opinion (Do not read.)

(If Q23, Q24 and/or Q25 = fair, poor or very poor, continue with Q27. Otherwise, skip to Q28.)
27. Why did you rate any of these things about the counselor as fair, poor or very poor?
(Record response _________________________________________)

28. Now I’m going to read you a list of some things a person might want to talk to a
counselor about. As I read each one, please answer yes or no to tell me if that was
something you wanted to talk about. Did you want to talk to the counselor about:
(Read responses. Select all that apply.)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.

How your Social Security benefits are affected by working
How your health insurance is affected by working
How to participate in the “Ticket” program
Where to get help finding, keeping or changing a job, including increasing or
decreasing the hours you work or your rate of pay
Where to get help finding special accommodations to be able to work
Where to get help paying for work-related expenses or training
How to report your earnings to Social Security or other agencies
How to deal with an overpayment caused by working
Forms or letters you received from Social Security or other agencies
Other (Do not read.) (Record response _____________________________)
Don’t know/refused (Do not read.)
(If only one response is given to Q28, skip to Q30.)

29. Out of the things you just identified, what was the main thing you wanted to talk about?
Was it:
(Read responses. Enter one response.)
(Read responses from Q28 to aid recall, if necessary.)

30. Thinking about all the information and help you received from the counselor, I’d like
you to tell me whether you strongly agree, somewhat agree, somewhat disagree or

8
strongly disagree with each of the following statements. I felt confident that the
information the counselor gave me was correct. Do you:
(Read rating scale. Enter one response.)
a.
b.
c.
d.
e.

Strongly agree (Skip to Q32.)
Somewhat agree (Skip to Q32.)
Somewhat disagree, or
Strongly disagree with this statement
No opinion
(Do not read.) (Skip to Q32.)

31. Why do you disagree? (Record response _________________________________)
32. The counselor clearly explained how working and earning money would affect my cash
benefits, medical insurance and other types of assistance. Do you:
(Read rating scale. Enter one response.)
a.
b.
c.
d.
e.

Strongly agree
(Skip to Q34.)
Somewhat agree
(Skip to Q34.)
Somewhat disagree, or
Strongly disagree with this statement
No opinion
(Do not read.) (Skip to Q34.)

33. Why do you disagree? (Record response ________________)

34. After talking with the counselor I knew what I was supposed to do or what was
supposed to happen next. Do you:
(Read rating scale. Enter one response.)
a.
b.
c.
d.
e.

Strongly agree
(Skip to Q36.)
Somewhat agree
(Skip to Q36.)
Somewhat disagree, or
Strongly disagree with this statement
No opinion
(Do not read.) (Skip to Q36.)

35. Why do you disagree? (Record response _________________)

9
36. Did the counselor ever write something for you that explained how working would
affect your personal situation and benefits, or a plan for using work incentives to help
you go to work?
(Do not read responses. Enter one response.)
a.
b.
c.

Yes
No
(Skip to Q43.)
Don’t remember (Skip to Q43.)

37. Did the counselor review the written explanation with you?
(Do not read responses. Enter one response.)
a.
b.
c.

Yes
No
(Skip to Q39.)
Don’t remember (Skip to Q39.)

38. Did the counselor review it with you in person or over the phone?
(Do not read responses. Enter one response.)
a.
b.
c.

In person
Over the phone
Don’t remember

39. Tell me whether you agree or disagree with these statements. The personal written
explanation the counselor gave me was clear. Do you:
(Read rating scale. Enter one response.)
a.
b.
c.
d.
e.

Strongly agree
Somewhat agree
Somewhat disagree, or
Strongly disagree
No opinion
(Do not read.)

10
40. The personal written explanation the counselor gave me was helpful. Do you:
(Read rating scale. Enter one response.)
a.
b.
c.
d.
e.

Strongly agree
Somewhat agree
Somewhat disagree, or
Strongly disagree
No opinion
(Do not read.)

(If Q39 and/or Q40 = somewhat or strongly disagree, continue with Q41. Otherwise, skip to
Q42.)
41. Why do you feel the written explanation was not (if only Q39 = somewhat or strongly
disagree, insert: “clear”); (if only Q40 = somewhat or strongly disagree, insert:
“helpful”); (if both Q39 and Q40 = somewhat or strongly disagree, insert: “clear or
helpful”)? (Record response _____________________________________________)

42. How did you use the written explanation from the counselor? Did you use it:
(Read responses. Select all that apply.)
a.
b.
c.
d.
e.
f.

To remind you what the counselor told you about your benefits and working
To remind you what your next steps should be about your benefits and working
To help you explain the counselor’s information and recommendations to other
organizations, such as Vocational Rehabilitation, or to your friends and family, or
Did you use it for some other purpose? (Record response _________________)
Didn’t use it
(Do not read.)
Don’t remember
(Do not read.)

43. Did the counselor ever contact someone else on your behalf, such as Social Security,
Vocational Rehabilitation (VR), or the Employment Network (EN)?
(Do not read responses. Enter one response.)
a.
b.
c.

Yes
(If Q36 equals “yes,” skip to Q46; if Q36 equals “no,” skip to Q48.)
No
Don’t remember (If Q36 equals “yes,” skip to Q46; if Q36 equals “no,” skip to Q48.)

11
44. Tell me whether you agree or disagree with the following statements. It was helpful
when the counselor contacted someone else for me. Do you:
(Read rating scale. Enter one response.)
a. Strongly agree (Skip to Q46.)
b. Somewhat agree (Skip to Q46.)
c. Somewhat disagree, or
d. Strongly disagree
e. No opinion
(Do not read.) (Skip to Q46.)
45. Why do you disagree? (Record response _________________)

46. When the counselor had to take some action on my case, for example, send me
something in the mail or make a phone call for me, they did it promptly. Do you:
(Read rating scale. Enter one response.)
a.
b.
c.
d.
e.

Strongly agree
(Skip to Q48.)
Somewhat agree
(Skip to Q48.)
Somewhat disagree, or
Strongly disagree
No opinion
(Do not read.) (Skip to Q48.)

47. Why do you disagree? (Record response _________________)

48. Did the counselor give you any other written material, such as pamphlets, booklets or
fact sheets, with information about working and disability benefits?
(Do not read responses. Enter one response.)
a.
b.
c.

Yes
No
(Skip to Q51.)
Don’t remember (Skip to Q51.)

12
49. Tell me whether you agree or disagree with this statement. The pamphlets and
booklets I received from the counselor helped me understand how work and earnings
affect my benefits. Do you:
(Read rating scale. Enter one response.)
a.
b.
c.
d.
e.

Strongly agree
(Skip to Q51.)
Somewhat agree
(Skip to Q51.)
Somewhat disagree, or
Strongly disagree
No opinion
(Do not read.) (Skip to Q51.)

50. Why do you disagree? (Record response _________________)

51. Considering all the information and help given you by the counselor from (insert site
name), how would you rate the service provided overall? Was the service:
(Read rating scale. Enter one response.)
a.
b.
c.
d.
e.
f.
g.

Excellent
Very good
Good
Fair
Poor, or
Very poor
No opinion

(Skip to Q53.)
(Skip to Q53.)
(Skip to Q53.)

(Do not read.) (Skip to Q53.)

52. Why did you say the service provided overall was (insert response from Q51)?
(Record response ________________________________________________)

Now Social Security would like to know a little more about you.
53. First, were you working at the time you first talked with the counselor?
(Do not read responses. Enter one response.)
a.
b.
c.

Yes
No
(Skip to Q57.)
Don’t know/refused (Skip to Q60.)

13

54. Were you working full time (that is, 30 or more hours per week) or part time (less than
30 hours per week)?
(Do not read responses. Enter one response.)
a.
b.
c.

Full time
Part time
Don’t remember/refused

55. How did the information the counselor gave you affect your decision to continue
working? After speaking with the counselor did you:
(Read responses; stop reading as soon as a response is chosen. Enter one response.)
a.
b.
c.
d.
e.

Keep working at the same rate
Increase the number of hours you worked
Decrease the number of hours you worked, or
Did you stop working
(Skip to Q58.)
Don’t know/refused
(Do not read.) (Skip to Q58.)

56. After speaking to the counselor, did you continue working at the same place or did you
change employers?
(Do not read responses. Enter one response.)
a.
b.
c.

Continued at same place
Changed employers
Don’t know/refused (Do not read.)
(All responders to Q56 skip to Q58.)

57. How did the information the counselor gave you affect your decision to start working
or not to work? After speaking with the counselor did you:
(Read responses; stop reading as soon as a response is chosen. Enter one response.)
a.
b.
c.
d.

Remain unemployed
Start working part time (less than 30 hours per week), or
Start working full time (30 hours or more per week)
Don’t know/refused (Do not read.)

14

58. Besides the information the counselor gave you, do you feel that there were other
things in your life that affected your decision about working?
(Do not read responses. Enter one response.)
a.
b.
c.

Yes
No
(Skip to Q60.)
Don’t know/refused (Skip to Q60.)

59. What were the other things that affected your decision about working?
(Do not read responses. Select all that apply.)
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.

Medical condition
Fear of losing monthly benefits
Fear of losing medical insurance (Medicaid or Medicare)
Child care issue
Family situation other than child care
General education/literacy issue
Specific job training issue (e.g., using computers or other technology)
Availability of jobs in area
Inability to find the help needed to get a job
Transportation issue
Language barrier
Other (Record response ___________________________________________)
Don’t know/refused

60. Are you working right now?
(Do not read responses. Enter one response.)
a. Yes
b. No
c. Don’t know/refused

(Skip to Q63.)
(Skip to Q63.)

61. How many hours do you usually work in a week? _____________
(If respondents indicate that hours vary, try to get an estimate/average.)

15
62. How much do you earn per hour? $______
(If respondents are not able to give hourly rate, record the earnings they can provide and
indicate the frequency (week/month/year).)

63. What is the highest grade you completed in school?
(Do not read responses. Enter one response. If respondent is reluctant to give information,
offer to read responses.)
a.
b.
c.
d.
e.
f.
g.

Not a high school graduate
High school graduate or equivalent (GED)
Trade/technical/vocational training graduate
Some college
College graduate
Graduate degree or postgraduate training
Don’t know/refused (Do not read.)

64. Do you have any other comments about the information or services you received from
the counselor?
(Do not read responses. Enter one response.)
a.
b.
c.

Yes
(Record response __________________________________________)
No
Don’t know/refused

CLOSING:

That’s all the questions I have for you today and I want to thank you for taking
time to be in this survey.

Work Incentives Planning and Assistance (WIPA) Survey
Prenotice Letter

Dear (insert participant’s name):
Our records show that you received information or other services from (insert site name) under a
special program to help people with disabilities who want to work. Through the Work Incentives
Planning and Assistance program, counselors provide important information to people about
what happens to their monthly disability benefits, health insurance, etc., if they work. The
counselors also explain special rules called work incentives that are available to help people who
want to work. We are conducting a survey to find out how satisfied you were with the
information and services you received from the counselors at (insert site name) under this
program.
A few days from now, an interviewer from (insert contractor name) will be calling to ask you to
take part in our survey. Please be assured that (insert contractor name) will only give your
responses to my staff here at Social Security and will not use them for any other purpose. Social
Security will report the survey results by summarizing the answers of everyone who takes the
survey; we will not report any individual responses.
The telephone number we have for you is [(###) ###-####]. If this number is incorrect, or if
there is another number that is more convenient for us to reach you on, please contact (insert
contractor name) toll-free on (insert contractor’s toll-free phone number) to give them that
number.
If you have a question about your benefits, please call Social Security’s toll-free information line
at 1-800-772-1213. (Neither my staff nor the interviewers at (insert contractor name) are able to
answer questions about your benefits.)
The survey will only take about 20 minutes to complete and it can be scheduled at your
convenience. While your participation is voluntary, we hope you will take the time to be in the
survey because your opinion matters. Your answers and comments will help Social Security
serve you better.

Sincerely,

Kelly Croft
Deputy Commissioner for Quality Performance
Social Security Administration

PRIVACY ACT STATEMENT
The Social Security Administration is authorized to collect the information for this survey under
Executive Order 12862, “Setting Customer Service Standards”. Your response to these
questions is strictly voluntary. The information you provide will be used to help us improve the
service that we give you. Your response will not be disclosed to any other government or private
agency.

PAPERWORK REDUCTION ACT STATEMENT
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by
Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions
unless we provide a valid Office of Management and Budget (OMB) control number. The OMB
control number for this survey is 0960-0526. We estimate that it will take about 20 minutes to
complete this survey. This includes the time it will take to listen to the questions and give your
responses. You may send comments on our time estimate above to: Social Security
Administration, 6401 Security Boulevard, Baltimore, MD 21235-0001. Send only comments
relating to our time estimate to this address.