Individual Generic Clearance Surveys

OMB Control No. 0960-0526
Expiration Date: 8/31/2012

Give Social Security a Report Card…
E = Excellent

VG = Very Good

G = Good

F = Fair

P = Poor

VP = Very Poor

Based on your recent visit, mark [X] ONE rating for:

E

VG

G

F

P

VP

1.

Office location

E

VG

G

F

P

VP

2.

Office hours

E

VG

G

F

P

VP

3.

Signs/instructions explaining how to check in
when you got to the office

E

VG

G

F

P

VP

4.

Office comfort (seating, temperature, etc.)

E

VG

G

F

P

VP

5.

Office appearance (clean, pleasant, etc.)

E

VG

G

F

P

VP

6.

Office privacy

E

VG

G

F

P

VP

7.

Did you have an appointment?

Mark [X] one.

Yes

 (Go to 8.)

No  (Skip to 9.)

8.

Convenience of your appointment

E

VG

G

F

P

VP

9.

Waiting time to be served in the office

E

VG

G

F

P

VP

10.

About how many minutes did you have to wait?

Mark [X] only ONE.

Up to 10 minutes
More than 10 and up to 30 minutes
More than 30 and up to 60 minutes
More than 60 minutes
11.

Helpfulness of the staff

E

VG

G

F

P

VP

12.

Courtesy of the staff

E

VG

G

F

P

VP

13.

How well the staff knew their jobs

E

VG

G

F

P

VP

14.

How clearly the staff explained things

E

VG

G

F

P

VP

15.

Was Social Security able to take care of your business completely that day? Mark [X]
one.

Yes

No

Please continue on the next page 

Mark [X] ONE rating.

E

VG

G

F

P

VP

E

VG

G

F

P

VP

16.

Overall, how would you rate Social Security’s
service for your recent office visit?

17.

If you contact Social Security again, what are you most likely to do? Will you: Mark [X]
only ONE.

Call Social Security’s 800 number
Call the local Social Security office
Visit the local office
Use the Internet or email
Other Explain:__________________________________________
Social Security has its own Internet site, www.socialsecurity.gov, that provides Social Security
information and services online. We’d like to ask you a few questions about doing business on
the Internet.
18.

First, do you currently use the Internet? Mark [X] one

Yes
19.

No  (Skip to 21.)

Have you ever visited Social Security’s Internet site? Mark [X] one

Yes
20.

No

If you could have taken care of your recent business by using the Internet instead of
visiting Social Security, how likely would you have been to do that? Would you have
been:
Mark [X] only ONE.

Very likely
Somewhat likely
Not very likely, or
Not at all likely to use the Internet instead of visiting
21. Please use this space to explain why you rated any item “F” (fair), “P” (poor), or “VP”
(very poor) or to explain any of your other answers.
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
_______________________________________________________________________________________
Thank you for taking the time to rate Social Security!
Please send us your “Report Card” in the enclosed postage-paid envelope as soon as possible.

FY 2010 Office Visitor Survey - Pre-Notice Postcard

Dear Social Security Customer:
Social Security believes that conducting surveys is one of the best ways to find out how
well we are serving you. That’s why we will soon be asking you to give us your opinion
about the service you received during a recent visit to a local Social Security office or
Social Security hearings office.
In a few days, you will receive a short questionnaire in the mail from [insert contractor
name], who is conducting this survey for Social Security. When you receive their
envelope, we hope that you will take the time to answer our questions and tell us what
you think of our service.
We look forward to hearing your opinions.
Kelly Croft
Deputy Commissioner for Quality Performance
Social Security Administration

FY 2010 Office Visitor Survey – Privacy Act - English

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, OMB No. 0960-0526, 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 display a valid Office of
Management and Budget control number. We estimate that it will take about 5 minutes
to participate in this activity. You may send comments on our time estimate above to:
Social Security Administration, 6401 Security Blvd., Baltimore, MD 21235-0001. Send
only comments relating to our time estimate to this address, not the completed form.

FY 2010 Office Visitor Survey – Follow-up Cover Letter

Dear [Insert Name]:
About a week ago we sent you a survey form, “Give Social Security a Report Card,” to
find out how well we served you when you visited the local Social Security office or the
Social Security hearings office. We haven’t yet heard from you and it’s important that
we gather opinions from as many people as possible. If you have already mailed in your
completed survey form, please discard this letter. We sincerely appreciate your help, and
we look forward to receiving your response.
However, if you have not yet had time to fill out and return your survey, please take a
few minutes right now to do that. The form is short and takes less than 5 minutes to
complete. In case you misplaced the survey, we have enclosed another copy along with a
postage-paid return envelope.
Please be assured that [insert contractor name], who is conducting this survey for us, 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.
If you have a question about Social Security benefits, please visit our web site at
www.socialsecurity.gov or call our toll-free information line at 1-800-772-1213. (To
protect your privacy, my staff cannot answer questions about your eligibility or benefits.)
We would appreciate receiving your completed survey as soon as possible.
Sincerely,

Kelly Croft
Deputy Commissioner for Quality Performance
Social Security Administration
Enclosures

FY 2010 Office Visitor Survey – Privacy Act - English

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, OMB No. 0960-0526, 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 display a valid Office of
Management and Budget control number. We estimate that it will take about 5 minutes
to participate in this activity. You may send comments on our time estimate above to:
Social Security Administration, 6401 Security Blvd., Baltimore, MD 21235-0001. Send
only comments relating to our time estimate to this address, not the completed form.