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pdfDisability Report (3368) Survey
Prenotice Letter for Traditional Applicants
Dear (insert applicant’s name):
Social Security would like your help to improve the service it gives the public. Our records
show that you recently filed an application for Social Security disability benefits. As one step in
the application, you had to give Social Security information about your medical condition, work
history, and education. We are conducting a survey to ask how easy or hard it was to do that.
A few days from now, an interviewer from [insert: contractor name] will be calling to ask you
to take part in our survey. Please be assured that [insert: contractor name] 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.
The telephone number we have for you is [insert: applicant telephone number]. If this number
is incorrect, or if there is another number that is more convenient for us to reach you on, please
contact [insert: contractor name] toll-free on [insert: contractor’s toll-free phone number] to
give them that number.
If you have a question about your benefits, please call Social Security’s toll-free information line
at 1-800-772-1213. (Neither my staff nor the interviewers at [insert: contractor name] are able
to answer questions about your benefits.)
The survey will only take about 20 minutes to complete and it can be scheduled at your
convenience. While your participation is voluntary, we hope you will take the time to be in the
survey because your opinion matters. Your answers and comments will help Social Security
serve you better.
Sincerely,
Ronald T. Raborg
Deputy Commissioner for Quality Performance
Social Security Administration
Disability Report (3368) Survey
Prenotice Letter for Internet Applicants
Dear (insert applicant’s or third party completer’s name):
Social Security would like your help to improve the service it gives the public. Our records
show that you recently [insert for applicants: filed] [insert for third party completers: helped
(claimant name) file] an application for Social Security disability benefits. As one step in the
application, you completed the online Disability Report, which collected information about
[insert for applicants: your] [insert for third party completers: (claimant name)’s] medical
condition, work history, and education. We are conducting a survey to ask about your
experience using the online Disability Report.
A few days from now, an interviewer from [insert: contractor name] will be calling to ask you
to take part in our survey. Please be assured that [insert: contractor name] 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.
The telephone number we have for you is [insert telephone number for applicant or third party
completer as appropriate]. If this number is incorrect, or if there is another number that is more
convenient for us to reach you on, please contact [insert: contractor name] toll-free on [insert:
contractor’s toll-free phone number] to give them that number.
If you have a question about your benefits, please call Social Security’s toll-free information line
at 1-800-772-1213. (Neither my staff nor the interviewers at [insert: contractor name] are able
to answer questions about your benefits.)
The survey will only take about 20 minutes to complete and it can be scheduled at your
convenience. While your participation is voluntary, we hope you will take the time to be in the
survey because your opinion matters. Your answers and comments will help Social Security
serve you better.
Sincerely,
Ronald T. Raborg
Deputy Commissioner for Quality Performance
Social Security Administration
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 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 provide a valid Office of Management and Budget (OMB) control number. The OMB
control number for this survey is 0960-0526. We estimate that it will take about 20 minutes to
complete this survey. This includes the time it will take to listen to the questions and give your
responses. You may send comments on our time estimate above to: Social Security
Administration, 1338 Annex Building, Baltimore, MD 21235-6401. Send only comments
relating to our time estimate to this address.
FY 2011 Disability Report Survey
Traditional Filers Questionnaire
Intro: As part of the application for disability benefits, Social Security asks for information
about your medical condition, your doctors and treatments, your previous jobs, and your
education. Most of the questions in this survey are about how easy or hard it was to give
Social Security that information.
1.
At the time you decided to file for disability benefits, how did you first contact
Social Security? Did you:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
g.
2.
Call Social Security’s national 800 number
Call your local Social Security office
Visit your local Social Security office, or
Visit Social Security’s website
Use some other way [Do not read; record response; skip to Q3.]
Don’t know
[Do not read; skip to Q3.]
Refused
[Do not read; skip to Q3.]
[If Q1 = a, b, or c, read version 1:]
How clearly did the employee you spoke with explain what you needed to do to file
for benefits? Was their explanation:
[If Q1 = d, read version 2:]
How clearly did Social Security’s website explain what you needed to do to file for
benefits? Was the explanation:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very clear
Somewhat clear
Not very clear, or
Not at all clear
Don’t know
[Do not read.]
Refused
[Do not read.]
3.
Social Security has a Disability Starter Kit, which is a guide that explains what you
should know about disability benefits and how to prepare to apply. Social Security
may have sent you a Disability Starter Kit in the mail or suggested that you go to
the online version on their website. Did you use a Disability Starter Kit to help you
prepare for your interview?
[Do not read responses; select only one response.]
a.
b.
c.
d.
4.
Yes
No
Don’t know
Refused
[Skip to Q5.]
[Skip to Q5.]
[Skip to Q5.]
How helpful was the Disability Starter Kit? Was it:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
5.
Very helpful
Somewhat helpful
Not very helpful, or
Not at all helpful
Don’t know
[Do not read.]
Refused
[Do not read.]
Now I’d like you to think about the day Social Security interviewed you. Did you
give your medical information to a Social Security employee in person or over the
telephone?
[Do not read responses; select only one response.]
a.
b.
c.
d.
e.
In person
Over the phone
I did not have an interview with Social Security
Don’t know
Refused
[Skip to end.]
2
6.
Did you do that by yourself, or did someone else, such as a friend or relative, help
you?
[Do not read responses; select only one response.]
a.
b.
c.
d.
7.
By myself
Someone else helped me
Don’t know
Refused
Did you make an appointment for your interview?
[Do not read responses; select only one response.]
a.
b.
c.
d.
8.
Yes
No
Don’t know
Refused
[Skip to Q10.]
[Skip to Q10.]
[Skip to Q10.]
How would you rate how soon you could get an appointment? Would you say it
was:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
g.
h.
Excellent
Very good
Good
Fair
Poor, or
Very poor
Don’t know
Refused
[Do not read.]
[Do not read.]
[Continue with Q9 if Q5 = a (in person); otherwise, skip to Q10.]
3
9.
On the day of your appointment, how would you rate the length of time you had to
wait in the reception area before you spoke to the Social Security interviewer who
completed your disability application? Would you say it was:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
g.
h.
Excellent
Very good
Good
Fair
Poor, or
Very poor
Don’t know
Refused
[Do not read.]
[Do not read.]
10. How would you rate the amount of time the interviewer spent with you? Was it:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
g.
h.
Excellent
Very good
Good
Fair
Poor, or
Very poor
Don’t know
Refused
[Do not read.]
[Do not read.]
11. Now I’m now going to ask you how easy or hard it was to give the different kinds
of information the interviewer asked for. First, how easy or hard was it to give
your medical information, for example, doctors’ names, medications, or dates of
tests? Was it:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very easy
Somewhat easy
Somewhat hard, or
Very hard
Don’t know
Refused
[Skip to Q13.]
[Skip to Q13.]
[Do not read.] [Skip to Q13.]
[Do not read.] [Skip to Q13.]
4
12. I’m going to read you a list of the types of medical information the interviewer
might have asked you to give. Please say “yes” when I read the ones you thought
were hard to answer. Was it hard to give:
[Read responses; select all that apply.]
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Doctors’ names and addresses
Dates of doctor visits
Names and addresses of hospitals or clinics
Dates of hospital or clinic visits
Names of medicines
Types of tests or treatments
Dates of tests or treatments
Some other information [Record response _______________________ ]
Don’t know
[Do not read.]
Refused
[Do not read.]
13. The interviewer also asked you to describe the types of treatments you had and
what they were for. How easy or hard was it to do that? Was it:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very easy
Somewhat easy
Somewhat hard, or
Very hard
Don’t know
Refused
[Skip to Q15.]
[Skip to Q15.]
[Do not read.] [Skip to Q15.]
[Do not read.] [Skip to Q15.]
14. Can you tell me what was hard about that?
[Do not read responses; select all that apply.]
a.
b.
c.
d.
e.
f.
g.
h.
To be sure what I said was clear and complete
Don’t understand the medical terms well enough to talk about them
Have more than one condition/have had many different treatments
My medical condition or the effects of my medication made it hard
Hard to remember everything
Some other reason
[Record response _________________________ ]
Don’t know
Refused
5
15. How easy or hard was it to answer the interviewer’s questions about your job
history? Was it:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very easy
[Skip to Q17.]
Somewhat easy [Skip to Q17.]
Somewhat hard, or
Very hard
Don’t know
[Do not read.] [Skip to Q17.]
Refused
[Do not read.] [Skip to Q17.]
16. I’m going to read a list of the types of job history information the interviewer
might have asked you to give. Please say “yes” when I read the ones you thought
were hard to answer. Was it hard:
[Read responses; select all that apply.]
a.
b.
c.
d.
e.
f.
g.
h.
Giving the date the condition first bothered you and when it kept you from working
Giving details about any changes in the job caused by the condition
Explaining why you stopped working
Giving details about the job titles and dates worked at that job in the last 15 years
Giving details about the hours and pay at the jobs, or
Giving some other information
[Record response ________________ ]
Don’t know
[Do not read.]
Refused
[Do not read.]
17. The interviewer also asked about your education and any special training you may
have had. How easy or hard was it to give this information? Was it:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very easy
[Skip to Q19.]
Somewhat easy [Skip to Q19.]
Somewhat hard, or
Very hard
Don’t know
[Do not read.] [Skip to Q19.]
Refused
[Do not read.] [Skip to Q19.]
6
18. Can you tell me what information was hard to give? Was it:
[Read responses; select all that apply.]
a.
b.
c.
d.
e.
f.
Names of schools
Dates attended
Describing special training or programs, or
Some other information [Record response _______________________.]
Don’t know
[Do not read.]
Refused
[Do not read.]
19. Now I’d like you to think about the Social Security employees you spoke with when
you applied for disability benefits. How would you rate their courtesy? Was it:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
g.
h.
Excellent
Very good
Good
Fair
Poor, or
Very poor
Don’t know
Refused
[Do not read.]
[Do not read.]
20. How would you rate the helpfulness of the employees? Was it:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
g.
h.
Excellent
Very good
Good
Fair
Poor, or
Very poor
Don’t know
Refused
[Do not read.]
[Do not read.]
7
21. How would you rate how well they knew their jobs? Would you say their job
knowledge was:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
g.
h.
Excellent
Very good
Good
Fair
Poor, or
Very poor
Don’t know
Refused
[Do not read.]
[Do not read.]
22. After your interview with Social Security, did you receive any other forms in the
mail asking you to give more information about your medical condition, job
history, or your daily activities?
[Do not read responses; select only one response.]
a.
b.
c.
d.
Yes
No
Don’t know
Refused
[Skip to Q24.]
[Skip to Q24.]
[Skip to Q24.]
23. How easy or hard was it to complete these forms? Was it:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very easy
Somewhat easy
Somewhat hard, or
Very hard
Don’t know
[Do not read.]
Refused
[Do not read.]
8
24. Overall, thinking about how easy or hard it has been filing for disability benefits,
how would you rate the experience so far? Has it been:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very easy
Somewhat easy
Somewhat hard, or
Very hard
Don’t know
[Do not read.]
Refused
[Do not read.]
25. Is there anything else you would like to tell Social Security about your experience
filing for disability benefits?
[Do not read responses; select only one response.]
a.
b.
c.
d.
Yes
[Record response _________________________ ]
No
Don’t know
Refused
Now I have just a few more questions to help Social Security better understand your
answers.
26. What is your age?
[Do not read responses; select only one response.]
a.
b.
c.
d.
e.
f.
g.
h.
i.
Under 18
18 – 24
25 – 34
35 – 44
45 – 54
55 – 64
65 and over
Don’t know
Refused
9
27. What is the highest level of education you have completed?
[Do not read responses; select only one response.]
a.
b.
c.
d.
e.
f.
g.
h.
Less than high school graduate
High school graduate/GED
Some college
Trade/technical/vocational training
College graduate
Postgraduate work or degree
Don’t know
Refused
28. Do you currently use the Internet?
[Do not read responses; select only one response.]
a.
b.
c.
d.
Yes
No
Don’t know
Refused
[Skip to end.]
[Skip to end.]
[Skip to end.]
29. How would you rate your level of experience using the Internet? Would you
describe yourself as:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very experienced
Somewhat experienced
Not very experienced, or
Not at all experienced
Don’t know
[Do not read.]
Refused
[Do not read.]
10
I’m going to read you a short list of activities that some people do on the Internet. I’d like
to know how often you do each of these things online. Do you:
[Read responses; select only one response.]
a. Often b. Sometimes c. Never
d. Don’t Know
[Do not read.]
e. Refused
[Do not read.]
30. Send e-mail
31. Instant message or
chat
32. Look for information
33. Make purchases
34. Bank or pay bills
35. Social Security has an online Disability Report that people can use to give their
medical information instead of having an interview with an employee. Were you
aware of the online Disability Report?
[Do not read responses; select only one response.]
a.
b.
c.
d.
Yes
No
Don’t know
Refused
[Skip to end.]
[Skip to end.]
36. [If Q35 = a (yes), read version 1:]
Did you ever consider using it?
[If Q35 = b (no), read version 2:]
Would you have considered using it?
[Do not read responses; select only one response.]
a.
b.
c.
d.
Yes
No
Don’t know
Refused
[If Q35 = a (yes), continue to Q37. If Q35 = b (no), skip to end.]
[Skip to end.]
[Skip to end.]
11
37. [If Q35 = a (yes) and Q36 = a (yes), read version 1:]
Can you tell me why you decided not to use it?
[If Q35 = a (yes) and Q36 = b (no), read version 2:]
Can you tell me why you didn’t want to use it?
[If Q35 = b (no) and Q36 = b (no), read version 3:]
Can you tell me why you wouldn’t want to use it?
[Do not read responses; select all that apply.]
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
Prefer to speak to a person
Online Disability Report too complicated/hard
Concerned about security and/or privacy of my information
Thought it would take too long on the Internet
Didn’t have the necessary information
Don’t have the necessary computer skills or experience
Computer is too old/Internet service is too slow
Started it online, but Social Security contacted me before I was done
Some other reason
[Record response _______________ ]
Don’t know
Refused
CLOSING: That’s all the questions I have for you today. Thank you for taking the time to be
in this survey.
12
FY 2011 Disability Report Survey
i3368 Users Questionnaire
Intro: As part of the application for disability benefits, Social Security asks for information
about your medical condition, your doctors and treatments, your previous jobs, and your
education. Most of the questions in this survey are about how easy or hard it was to
provide that information using Social Security’s online Disability Report.
1.
First, how did you hear about Social Security’s online Disability Report?
[Do not read responses; select all that apply.]
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
Social Security’s website
A search engine or website other than Social Security’s
A Social Security employee
A friend or relative
Written material from Social Security (e.g., pamphlets, yearly Social Security
statement, etc.)
A Doctor or other health care professional, social worker
A nonprofit organization that serves people with disabilities (e.g., the United
Cerebral Palsy Association, ARC, etc.)
An attorney or a paid professional disability consulting service (e.g., Allsup, Binder
& Binder, etc.)
Media (e.g. newspaper, magazine, TV or radio)
Somewhere else (e.g. employer, union, school, or church)
Don’t know
Refused
[If interviewing applicant, read Q2. If interviewing non-professional third party completer, skip
to Q3.]
2.
Did you fill out the online Disability Report by yourself or did someone else, such
as a friend or relative, help you?
[Do not read responses; select only one response.]
a.
b.
c.
d.
By myself
Someone else helped me
Don’t know
Refused
3.
How easy or hard was it to find the online Disability Report on Social Security’s
website? Was it:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
4.
Very easy
Somewhat easy
Somewhat hard, or
Very hard to find
Don’t know
[Do not read.]
Refused
[Do not read.]
How clearly did the website explain how the online Disability Report works?
Were the explanations:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
5.
Very clear
Somewhat clear
Not very clear, or
Not at all clear
Don’t know
[Do not read.]
Refused
[Do not read.]
Throughout the online Disability Report, there were instructions and examples
showing what information you needed to provide. Would you say these
instructions were:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very helpful
Somewhat helpful
Not very helpful, or
Not at all helpful
Don’t know
[Do not read.]
Refused
[Do not read.]
2
6.
Now I’m now going to ask you how easy or hard it was to give the different kinds
of information the Disability Report asked for. First, how easy or hard was it to
give your medical information, for example, doctors’ names, medications, or dates
of tests? Was it:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
7.
Very easy
Somewhat easy
Somewhat hard, or
Very hard
Don’t know
Refused
[Skip to Q8.]
[Skip to Q8.]
[Do not read.] [Skip to Q8.]
[Do not read.] [Skip to Q8.]
I’m going to read you a list of the types of medical information the report might
have asked you to give. Please say “yes” when I read the ones you thought were
hard to answer. Was it hard to give:
[Read responses; select all that apply.]
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
8.
Doctors’ names and addresses
Dates of doctor visits
Names and addresses of hospitals or clinics
Dates of hospital or clinic visits
Names of medicines
Types of tests or treatments
Dates of tests or treatments
Some other information [Record response _________________________.]
Don’t know
[Do not read.]
Refused
[Do not read.]
Some questions on the online Disability Report asked you to describe in your own
words the types of treatments you had and what they were for. How easy or hard
was it to do that? Was it:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very easy
Somewhat easy
Somewhat hard, or
Very hard
Don’t know
Refused
[Skip to Q10.]
[Skip to Q10.]
[Do not read.] [Skip to Q10.]
[Do not read.] [Skip to Q10.]
3
9.
Can you tell me what was hard about that?
[Do not read responses; select all that apply.]
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
Hard to put it in my own words – not good at expressing myself in writing
To be sure what I wrote was clear and complete
Don’t understand the medical terms well enough to write about them
Have more than one condition/have had many different treatments
My medical condition or the effects of my medication made it hard
Hard to remember everything
Needed more space on the online screens
Some other reason
[Record response _________________________ ]
Don’t know
Refused
10. There were also questions on the online Disability Report about your job history.
How easy or hard was it to give this information? Was it:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very easy
Somewhat easy
Somewhat hard, or
Very hard
Don’t know
Refused
[Skip to Q12.]
[Skip to Q12.]
[Do not read.] [Skip to Q12.]
[Do not read.] [Skip to Q12.]
11. I’m going to read a list of the types of job history information the report might
have asked you to give. Please say “yes” when I read the ones you thought were
hard to answer. Was it hard:
[Read responses; select all that apply.]
a.
b.
c.
d.
e.
f.
g.
h.
Giving the date the condition first bothered you and when it kept you from working
Giving details about any changes in the job caused by the condition
Explaining why you stopped working
Giving details about the job titles and dates worked at that job in the last 15 years
Giving details about the hours and pay at the jobs, or
Giving some other information [Record response _________________________ ]
Don’t know
[Do not read.]
Refused
[Do not read.]
4
12. Another group of questions on the online Disability Report asked about your
education and any special training you may have had. How easy or hard was it to
give this information? Was it:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very easy
Somewhat easy
Somewhat hard, or
Very hard
Don’t know
Refused
[Skip to Q14.]
[Skip to Q14.]
[Do not read.] [Skip to Q14.]
[Do not read.] [Skip to Q14.]
13. Can you tell me what information was hard to give? Was it:
[Read responses; select all that apply.]
a.
b.
c.
d.
e.
f.
Names of schools
Dates attended
Describing special training or programs, or
Some other information [Record response _________________________ ]
Don’t know
[Do not read.]
Refused
[Do not read.]
14. While you were entering information for your online Disability Report, were there
any items that you needed to change or any corrections you needed to make?
[Do not read responses; select only one response.]
a.
b.
g.
c.
Yes
No
Don’t know
Refused
[Skip to Q16.]
[Skip to Q16.]
[Skip to Q16.]
5
15. How easy or hard was it to make the changes or corrections? Was it:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very easy
Somewhat easy
Somewhat hard, or
Very hard
Don’t know
[Do not read.]
Refused
[Do not read.]
16. Did you contact Social Security for help with the online Disability Report while
you were working on it?
[Do not read responses; select only one response.]
a.
b.
c.
d.
Yes
No
Don’t know
Refused
[Skip to Q19.]
[Skip to Q19.]
[Skip to Q19.]
17. How did you contact Social Security? Did you:
[Read responses; select all that apply.]
a.
b.
c.
d.
e.
f.
Call Social Security’s national 800 number
Call the local Social Security office
Visit the local Social Security office, or
Send an e-mail to Social Security
Don’t know
[Do not read.]
Refused
[Do not read.]
18. Were you able to get the help you needed?
[Do not read responses; select only one response.]
a.
b.
c.
d.
Yes
No
Don’t know
Refused
6
19. The online Disability Report is set up so you can work on it in more than one
sitting. Did you complete it in one or more than one sitting?
[Do not read responses; select only one response.]
a.
b.
c.
d.
One sitting
[Skip to Q21.]
More than one sitting
Don’t know
[Skip to Q21.]
Refused
[Skip to Q21.]
20. Why did you decide to work on it in more than one sitting?
[Do not read responses; select all that apply.]
a.
b.
c.
d.
e.
f.
g.
h.
i.
Didn’t have information like addresses, dates or doctors’ names readily available
Disability Report is too long/has a lot of questions
Did not understand what questions meant/how to answer them
Because of my condition or the effects of my medication
Couldn’t figure out how to fix something that was wrong
Had trouble with my computer or Internet connection
Some other reason
[Record response _________________________ ]
Don’t know
Refused
21. Altogether, how much time did it take you to complete the online Disability
Report? Did you spend:
[Do not read responses; select only one response. If respondent is having trouble
recalling, offer to read ranges.]
a.
b.
c.
d.
e.
f.
g.
h.
1 hour or less
Over 1 hour and up to 2 hours
Over 2 hours and up to 3 hours
Over 3 hours and up to 4 hours
Over 4 hours and up to 5 hours, or
Over 5 hours
Don’t know
Refused
7
22. And how would you rate the amount of time it took? Would you say it was:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
g.
h.
Excellent
Very good
Good
Fair
Poor, or
Very poor
Don’t know
Refused
[Do not read.]
[Do not read.]
23. Considering everything we’ve talked about so far, how would you rate Social
Security’s online Disability Report? Would you say it was:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
g.
h.
Excellent
Very good
Good
Fair
Poor, or
Very poor
Don’t know
Refused
[Do not read.]
[Do not read.]
24. Filling out and submitting the online Disability Report is only one step in applying
for Social Security disability benefits. How clearly did Social Security’s website
explain what else you had to do to file your application? Was the explanation:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very clear
Somewhat clear
Not very clear, or
Not at all clear
Don’t know
Refused
[Skip to Q26.]
[Skip to Q26.]
[Do not read.] [Skip to Q26.]
[Do not read.] [Skip to Q26.]
8
25. Can you tell me what was unclear?
[Do not read responses; select all that apply.]
a.
b.
c.
d.
e.
f.
g.
Not sure what next steps would be/whether Social Security would contact me
Not sure what other documents/information Social Security needed
Not sure where to send information/documents
Not sure how long it would take to get a decision
Something else [Record response _________________________ ]
Don’t know
Refused
26. After you completed the online Disability Report, did you receive any other forms
in the mail asking you to give more information about your medical condition, job
history, or your daily activities?
[Do not read responses; select only one response.]
a.
b.
c.
d.
Yes
No
Don’t know
Refused
[Skip to Q28.]
[Skip to Q28.]
[Skip to Q28.]
27. How easy or hard was it to complete these forms? Was it:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very easy
Somewhat easy
Somewhat hard, or
Very hard
Don’t know
[Do not read.]
Refused
[Do not read.]
9
28. You may have already mentioned it earlier, but I need to ask you directly; did you
have any contact with a Social Security employee about your online Disability
Report?
[Do not read responses; select only one response.]
a.
b.
c.
d.
Yes
No
Don’t know
Refused
[Skip to Q30.]
[Skip to Q30.]
[Skip to Q30.]
29. How would you rate the quality of service Social Security employees provided,
such as their courtesy, helpfulness, job knowledge, and time spent with you? Was
their service:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
g.
h.
Excellent
Very good
Good
Fair
Poor, or
Very poor
Don’t know
Refused
[Do not read.]
[Do not read.]
30. Overall, thinking about how easy or hard it has been filing for disability benefits,
how would you rate the experience so far? Has it been:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very easy
Somewhat easy
Somewhat hard, or
Very hard
Don’t know
[Do not read.]
Refused
[Do not read.]
10
31. Is there anything else you would like to tell Social Security about your experience
filing for disability benefits?
[Do not read responses; select only one response.]
a.
b.
c.
d.
Yes
[Record response _________________________ ]
No
Don’t know
Refused
Now I have just a few more questions to help Social Security better understand your
answers.
32. What is your age?
[Do not read responses; select only one response.]
a.
b.
c.
d.
e.
f.
g.
h.
i.
Under 18
18 – 24
25 – 34
35 – 44
45 – 54
55 – 64
65 and over
Don’t know
Refused
33. What is the highest level of education you have completed?
[Do not read responses; select only one response.]
a.
b.
c.
d.
e.
f.
g.
h.
Less than high school graduate
High school graduate/GED
Some college
Trade/technical/vocational training
College graduate
Postgraduate work or degree
Don’t know
Refused
11
34. How would you rate your level of experience using the Internet? Would you
describe yourself as:
[Read responses; select only one response.]
a.
b.
c.
d.
e.
f.
Very experienced
Somewhat experienced
Not very experienced, or
Not at all experienced
Don’t know
[Do not read.]
Refused
[Do not read.]
I’m going to read you a short list of activities that some people do on the Internet. I’d like
to know how often you do each of these things online. Do you:
[Read responses; select only one response.]
a. Often b. Sometimes c. Never
d. Don’t Know
[Do not read.]
e. Refused
[Do not read.]
35. Send e-mail
36. Instant message or
chat
37. Look for information
38. Make purchases
39. Bank or pay bills
CLOSING: That’s all the questions I have for you today. Thank you for taking the time to be
in this survey.
12
| File Type | application/pdf |
| Author | IWS/LAN |
| File Modified | 2010-07-02 |
| File Created | 2010-07-02 |