Individual Generic Clearance Surveys

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

Give Social Security a Report Card...
Please answer the following questions to give us your opinion of the online application you recently
completed on Social Security’s website.
MARKING INSTRUCTIONS
Correct Marking Example: 
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Use blue or black pen or a number 2 pencil.
Do not use pens with ink that soaks through the paper.

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Make no stray marks.
Keep all entries within the boxes.

1. How did you hear about Social Security’s online application?
Mark all that apply.

□ From Social Security (an employee, their website, written material, etc.)
□ From a family member or friend
□ From a website other than Social Security’s
□ From a doctor or other health care professional, social worker
□ From a nonprofit organization that serves the aged or people with disabilities (United Cerebral
Palsy, ARC, etc.)

□ From an attorney or a paid professional consulting service (Allsup, Binder & Binder, etc.)
□ From the media (newspaper, magazine, TV or radio, etc.)
□ Somewhere else (employer, union, school, church, etc.)
2. Did you fill out the online application by yourself or was someone else there to help you with it?
Mark only ONE answer

□ Filled it out by myself

→Please skip to question 4.

□ Someone else helped me →Please continue with question 3.
3. Who helped you?
Mark only ONE answer

□ Non-professional (family member, friend, etc.)
□ Professional (attorney, social worker, doctor, etc.)

Please continue to the next page

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Excellent

Very
Good

Good

Fair

Poor

Very Poor

Not
Applicable

Please use the scale shown to rate the following aspects of your experience using Social Security’s online
application. If a question does not apply to you, please mark Not Applicable.

4.

Ease of finding the online application on Social Security’s
website

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5.

Number of pages you went through before you could start the
online application

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6.

Appearance of the online application pages (amount of
information, how the information is arranged, etc.)

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7.

How well Social Security’s website explained what information
and documents you needed to complete your online application

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Mark [X] ONE answer for every item.

When You Decided to File Online…

Completing the Online Application…
8.

Ease of answering the questions on the online application

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9.

Helpfulness of the explanations in the “More Info” links on the
online application

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10. Availability of help from Social Security to complete the online
application

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11. Length of time it took to complete the online application

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12. About how long did it take you complete the online application?
Mark only ONE answer

□ 15 minutes or less
□ Over 15 and up to 30 minutes
□ Over 30 and up to 45 minutes
□ Over 45 and up to 1 hour
□ Over 1 hour and up to 2 hours
□ More than 2 hours

Please continue to the next page

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Excellent

Very
Good

Good

Fair

Poor

Very Poor

Not
Applicable

13. What would happen after you submitted your online application

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14. Other information you needed to know about your benefits

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15. The security and privacy features of the website

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Mark [X] ONE answer for every item.

Explanations on Social Security’s Website About…

Your Overall Rating…

Very
Likely

Somewhat
Likely

Not very
Likely

Not at all
Likely

Not
Applicable

16. Overall opinion of Social Security’s online application

17. Recommend Social Security’s online application to others

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18. Use Social Security’s website for your future business (request
information, change your address, etc.)

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Mark [X] ONE answer for every item.

Your Likelihood to…

19. Please use this space to explain why you chose a rating of “fair,” “poor,” or “very poor” in any question on
this form, or to provide any other comments you may have about Social Security’s online application.

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.

Internet Report Card Survey - Prenotice 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
business you recently completed on our website.
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 online
service.
We look forward to hearing your opinions.
Kelly Croft
Deputy Commissioner for Quality Performance
Social Security Administration

Internet Report Card Survey – Privacy Act

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 read the instructions, gather the facts, and answer
the questions. 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.

Internet Report Card Survey – Initial Cover Letter

RE: [Insert type of online business from sample file]

Dear [Insert name from sample file]:
As I noted in my recent postcard, Social Security is conducting a survey to find out how well we
served you when you completed your recent business on our website. Please take 5 minutes to
fill out the enclosed "Report Card" and return the form as soon as possible in the postage-paid
envelope provided.
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 appreciate your taking time out of your busy schedule to answer our survey.
Sincerely,

Kelly Croft
Deputy Commissioner for Quality Performance
Social Security Administration
Enclosures

Internet Report Card Survey – Privacy Act

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 read the instructions, gather the facts, and answer
the questions. 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.

Internet Report Card Survey – Follow-up Cover Letter

RE: [Insert type of online business from sample file]

Dear [Insert name from sample file]:
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 completed your business on our website. 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.