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OMB Approval No. 1225-0059
Expiration Date: 11.30.2012
FMLA Customer Satisfaction Survey
The following questions ask you to rate the performance of the Wage and Hour Division (WHD) when it conducted its investigation of
your case. Please answer all of the questions. If you wish to comment on any question, please feel free to use the space at the end.
Thank you for your help.
1. How did you find out that WHD is the federal agency that enforces the Family and Medical Leave Act (FMLA)? (please mark your
answer with an X)
A. ______ From another person
B. ______ From something in the news media or printed material
C. ______ From the telephone directory or operator
D. ______ From the internet
2. If you have selected “A” for question number 1, who was that person? (please mark your answer with an X)
A. ______ A prior WHD contact
B. ______ A friend or family member
C. ______ A lawyer or an accountant
D. ______ A co-worker or your union
E. ______ From another agency
3. If you have selected “B” for question number 1, what was the form of media? (please mark your answer with an X)
A. ______ A poster
B. ______ A newspaper, television, or radio
C. ______ Other
4. Why did you request FMLA? Please select from the following 4 choices. (please mark your answer with an X)
A. ______ For your own serious health condition
B. ______ For the care of your child, spouse or parent who had a serious health condition
C. ______ For the foster care or adoption of a child
D. ______ For the birth or care of a newborn child
5. In what manner did you believe your employer violated the FMLA? You may select more than one response. (please mark your answer(s)
with an X)
A. ______ You were not provided the proper notification
B. ______ You were denied the appropriate leave
C. ______ The employer did not maintain your health benefits
D. ______ Your employment was terminated
E. ______ You were not reinstated to an equivalent position
F. ______ You were discriminated against for requesting or taking leave
G. ______ Other
6. Was your complaint found to be valid by WHD? (please mark your answer with an X)
q
YES
q
NO
7. If a violation was found based on your complaint against your employer at the time, how was it resolved? You may select more than
one response. (please mark your answer(s) with an X)
A. ______ You were given the appropriate leave
B. ______ You were reinstated in your job following the leave
C. ______ A discrimination issued was resolved
D. ______ You received back wages
E. ______ Your health benefits were restored
F. ______ You obtained your own attorney
G. ______ You were referred to another agency
H. ______ It was not resolved
I. ______ You don’t know
J. _____ Other
Continued
c
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8. How long did WHD tell you it would take to resolve your complaint? (please mark your answer with an X)
A. ________Less than 1 month
C. ________2 months
E. ________4 months
G. ________6 months or more
B. ________1 month
D. ________3 months
F. ________5 months
H. ________Don’t remember
9. Was your complaint resolved within the amount of time you were informed it would take? (please mark your answer with an X)
q
YES
q
q
NO
Don’t remember
10. How long do you believe it should have taken to resolve your complaint? (please mark your answer with an X)
A. ________Less than 1 month
C. ________ 2 months
E. ________4 months
B. ________1 month
D. ________3 months
F. ________5 months
G. ________6 months or more
11. Were you advised on the progress of your complaint? (please mark your answer with an X)
q
YES
q
NO
q
Don’t remember
12. Did WHD inform you of the final resolution regarding your complaint? (please mark your answer with an X)
q
YES
q
NO
13. If the answer to question 12 was YES, how were you informed? (please mark your answer with an X)
A. ______ By telephone
B. ______ By letter
C. ______ In person
14. How satisfied are you with the time it took to resolve your complaint? Please use the scale 1 trough 5, with ‘‘1” being VERY SATISFIED
and “5” being VERY DISSATISFIED. (circle one)
1
2
3
4
5
15. How do you rate the overall service provided by WHD in addressing your issues? Please use the scale 1 trough 5, with “1” being VERY
SATISFIED and “5” being VERY DISSATISFIED. (circle one)
1
2
3
4
5
16. What suggestions do you have to help us improve our services?
Public Burden Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to this collection of information unless it displays a valid OMB control number.
While the obligation to respond to this collection of information is voluntary, your answers to the enclosed questionnaire will be used to make improvements in how the
Wage and Hour Division performs its investigations with respect to timely service, communication and performance in protecting your rights to job protected family and
medical leave. We estimate it will take an average of 10 minutes to complete this collection of information, based on agency experience in the conduction of previous
costumer satisfaction surveys.. If you have any questions for reducing this burden, send them to the Administrator, Wage and Hour Division, Room S-3502, 200 Constitution
Avenue, N.W., Washington, D.C. 20210 or email DOL_PRA_PUBLIC@dol,gov and reference OMB No. 1225-0086. Note: please do not return the completed survey to this
address.
Confidentiality Statement
Responses to this data collection will be used only for statistical purposes. Your answers will be completely confidential to the maximum extent under the law. Your
employer does not know you have been sent this information, and will not see your answers. Your local WHD office will not see your answers either. Summary survey
results will only be reported to your local WHD office (no use of names or identifiers) for improvement purposes. The questionnaire does have a District Office identifier
code so that we can provide summary information. Your responses cannot be traced back to your name.
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| File Type | application/pdf |
| File Modified | 2011-05-02 |
| File Created | 2011-05-02 |