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pdfOMB Control Number 0960-0526
Expiration Date: 8/31/2012
FY 2010 Hearing Process Report Card Survey – Awards
Social Security is continually working to improve the service we provide the public. Please complete
this questionnaire to give us your opinion of the service you received when you requested a hearing
on your application for disability benefits.
MARKING INSTRUCTIONS
Correct Marking Example:
Very Good
Good
Fair
Poor
Very Poor
Not
Applicable
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.
Please use the scale shown to rate the following aspects of your hearing experience.
Mark [X] ONE answer for every item.
If a question does not apply to you, please mark Not Applicable.
Excellent
1.
Ease of finding information about how to file your
hearing request
2.
Quality of information you got from Social Security
explaining the hearing process
When you decided to request a hearing…
While you were waiting for your hearing to be held…
3.
Ease of contacting Social Security about your hearing
request
4.
Helpfulness of the information Social Security gave
you about your hearing request
How your hearing was held…
5.
6.
Did you have a representative, either an attorney or some other person, handle your hearing?
Mark only ONE answer.
Yes
No
Did you have a hearing with a judge face-to-face or by video conference?
Mark only ONE answer.
Hearing was face-to-face with a judge.
Hearing was by video conference with a judge.Please continue with question 7
No hearing was held with a judge.
Please continue with question 7
Please continue with question 14
PLEASE CONTINUE TO PAGE 2
Excellent
Very Good
Good
Fair
Poor
Very Poor
Not
Applicable
Location of the office where your hearing was held
How well the judge explained what would happen at
your hearing
9. How prepared the judge was to talk about the facts of
your case
10. Opportunity the judge gave you or your representative
to present the facts of your case
11. Courtesy of the judge
12. Length of time from the date you first requested your
hearing until it was held
13. Length of time from the date your hearing was held
until you received the decision
14. Overall length of time from the date you first requested
your hearing until you received the decision
15. How well the notice explained the decision on your
hearing
16. How well the notice explained the amount of your
benefits and when they would start
17. Helpfulness of the staff
18. Courtesy of the staff
19. How well the staff knew their jobs
20. Overall experience with the hearing on your disability
application
21. Overall opinion of Social Security’s service
Please use the scale shown to rate the following aspects
of your hearing experience.
Mark [X] ONE answer for every item.
When your hearing was held…
7.
8.
Waiting for the hearing and decision…
Notice of Social Security’s decision on your hearing…
Your overall experience with Social Security…
22. Please use the space below to tell us anything else about the service you received in connection
with your hearing.
OMB Control Number 0960-0526
Expiration Date: 8/31/2012
FY 2010 Hearing Process Report Card Survey – Denials
Social Security is continually working to improve the service we provide the public. Please complete
this questionnaire to give us your opinion of the service you received when you requested a hearing
on your application for disability benefits.
MARKING INSTRUCTIONS
Correct Marking Example:
Very Good
Good
Fair
Poor
Very Poor
Not
Applicable
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.
Please use the scale shown to rate the following aspects of your hearing experience.
Mark [X] ONE answer for every item.
If a question does not apply to you, please mark Not Applicable.
Excellent
1.
Ease of finding information about how to file your
hearing request
2.
Quality of information you got from Social Security
explaining the hearing process
When you decided to request a hearing…
While you were waiting for your hearing to be held…
3.
Ease of contacting Social Security about your hearing
request
4.
Helpfulness of the information Social Security gave
you about your hearing request
How your hearing was held…
5.
6.
Did you have a representative, either an attorney or some other person, handle your hearing?
Mark only ONE answer.
Yes
No
Did you have a hearing with a judge face-to-face or by video conference?
Mark only ONE answer.
Hearing was face-to-face with a judge.
Hearing was by video conference with a judge.Please continue with question 7
Please continue with question 7
PLEASE CONTINUE TO PAGE 2
Good
Fair
Poor
Very Poor
Not
Applicable
Please continue with question 14
Very Good
No hearing was held with a judge.
Excellent
Location of the office where your hearing was held
How well the judge explained what would happen at
your hearing
9. How prepared the judge was to talk about the facts of
your case
10. Opportunity the judge gave you or your representative
to present the facts of your case
11. Courtesy of the judge
12. Length of time from the date you first requested your
hearing until it was held
13. Length of time from the date your hearing was held
until you received the decision
14. Overall length of time from the date you first requested
your hearing until you received the decision
15. How well the notice explained the decision on your
hearing
16. How well the notice explained what to do if you
disagreed with the decision
17. Helpfulness of the staff
18. Courtesy of the staff
19. How well the staff knew their jobs
20. Overall experience with the hearing on your disability
application
21. Overall opinion of Social Security’s service
Please use the scale shown to rate the following aspects
of your hearing experience.
Mark [X] ONE answer for every item.
When your hearing was held…
7.
8.
Waiting for the hearing and decision…
Notice of Social Security’s decision on your hearing…
Your overall experience with Social Security…
22. Please use the space below to tell us anything else about the service you received in connection
with your hearing.
Hearings Report Card Survey
Initial Cover Letter – English
Dear Social Security Applicant:
Social Security is conducting a survey to get your opinion of the service you received when you
requested a hearing on your application for Social Security disability benefits. We would like to
hear from you even if you did not attend a hearing with a judge.
The survey is short and should only take 5 minutes to complete. Please take a few minutes now
to answer the questions and return the form as soon as possible in the postage paid envelope
provided. While you are not required to respond, your opinions are very important to us and we
would like to hear from as many people as possible.
Please be assured that [contractor], 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. Your participation in this survey will not
affect your eligibility for benefits or any business you have with Social Security.
If you have any questions about your hearing request or benefits, please call Social Security’s
toll-free information line at 1-800-772-1213 or visit our web site at www.socialsecurity.gov. (To
protect your privacy, neither my staff nor [contractor] can answer questions about your
eligibility or benefits.)
Thank you for sharing your opinions with us.
Sincerely,
Kelly Croft
Deputy Commissioner for Quality Performance
Social Security Administration
Enclosures
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 the survey form displays a valid Office of Management and Budget
control number. We estimate that it will take about 5 minutes to complete this survey. This
includes the time it will take 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.
Hearings Report Card Survey
Follow-up Postcard – English
Dear Social Security Customer:
About two weeks ago we sent you a survey form asking for your opinion of the service you
received for your recent business with Social Security.
If you have already mailed back your completed survey, thank you for your
quick response.
If not, please take 5 minutes now to complete and return the survey in the
postage-paid envelope provided.
If you no longer have the survey, you don’t need to do anything. [Contractor],
who is conducting the survey for us, will be mailing another form to you shortly.
Thank you for your help with this survey.
Kelly Croft
Deputy Commissioner for Quality Performance
Social Security Administration
Hearings Report Card Survey
Follow-up Cover Letter - English
Dear Social Security Applicant:
About a month ago we sent you a brief survey asking about the service you received when you
requested a hearing on your application for Social Security disability benefits. We haven’t yet
heard from you and it’s important that we gather opinions from as many people as possible. We
would like you to answer our survey even if you did not attend a hearing with a judge.
If you recently 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 returned the survey, please take 5 minutes now to complete it and send it back. For your
convenience, we have enclosed another copy along with a postage-paid return envelope.
Please be assured that [contractor], 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. Your participation in this survey will not
affect your eligibility for benefits or any business you have with Social Security.
If you have any questions about your hearing request or benefits, please call Social Security’s
toll-free information line at 1-800-772-1213 or visit our web site at www.socialsecurity.gov. (To
protect your privacy, neither my staff nor [contractor] can 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
| File Type | application/pdf |
| File Title | Disability Service Improvement – Post-Adjudicative Survey |
| Author | dpse |
| File Modified | 2009-09-01 |
| File Created | 2009-09-01 |