EEOICPA Customer Satisfaction Survey

5W66-01 Page 2

EEOICPA Customer Satisfaction Survey
The Division of Energy Employees Occupational Illness Compensation (DEEOIC) is committed to improving the services we provide, especially when it comes to processing claims. Your opinions are very important to us. Please complete this questionnaire to give us your views of the service you received during your claims process
MARKING INSTRUCTIONS Correct Marking Example: 
Use blue or black pen or a number 2 pencil.	Make no stray marks.
Do not use pens with ink that soaks through the paper.	Keep all entries within the boxes.

1.	How did you file your EEOICPA claim?	5.	Would you recommend this program to a friend with similar conditions?
	District Office		Yes
	Resource Center by mail		No
	Resource Center in person	Please explain why you would or why you would not recommend this program to a friend with similar conditions: _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Feel free to provide additional comments on an extra sheet of paper and return them with this survey (PLEASE CONTINUE TO PAGE 2)
	Online
	Other
2.	What type of claim did you file?
	Part B
	Part E
	Both
	Don’t know / don’t remember
3.	Did you file as an employee or a survivor?
	Employee
	Survivor
4.	What additional assistance would you like to see DEEOIC offer?
	Medical (such as help identifying physicians, pharmacies, and other health-care providers)  Impairment evaluation(s)  None
	Impairment evaluation(s)
	None
	Other (please specify)_________________ _______________________________________________________________________________________________________________________________________________________________________________ (PLEASE CONTINUE TO QUESTION 5)

For questions 6 through 8, using a scale of 1 to 5 where 1=Poor and 5=Excellent, please rate each of the following areas regarding the services you received from EEOICPA. If the area is not applicable to your experience, please select NA.

6.	Your Resource Center experience	Poor 1	2	3	4	Excellent 5	NA
a.	Responsiveness to your inquiries						
b.	Courtesy of staff						
c.	Explanation of claims process						
d.	Privacy/confidentiality of your personal information						
e.	Usefulness of educational/informational brochures						
g.	Overall Resource Center rating						

7.	Your District Office experience	Poor 1	2	3	4	Excellent 5	NA
a.	Responsiveness to your written inquiries						
b.	Responsiveness to your verbal inquiries						
c.	Courtesy of staff						
d.	Explanation of claims process						
e.	Explanation of the impairment and/or wage-loss process						
f.	Clarity of correspondence						
g.	Privacy/confidentiality of your personal information						
i.	Clarity and understandability of the recommended decision on your claim						
j.	Explanation of your right to object						
k.	Overall District Office rating						

8.	Your Final Adjudication Branch (FAB) experience	Poor 1	2	3	4	Excellent 5	NA
a.	Responsiveness to your written inquiries						
b.	Responsiveness to your verbal inquiries						
c.	Courtesy of staff						
d.	Explanation of the FAB review process						
e.	Experience with the hearing process						
e.	Clarity of correspondence						
f.	Privacy/confidentiality of your personal information						
h.	Clarity and understandability of the final decision on your claim						
i.	Overall FAB rating						

Thank you for your time!