Special 800# Caller Survey and FY 11 SNO Survey

Sample Notice for Persons with a Special Notice Option of

Certified Mail or Follow-up Phone Call

Date:

We would like your help to improve the service we give to blind or visually impaired persons. Our records show that you receive letters from us in a special notice format. We would like to find out if you are satisfied with the special notice format.

An interviewer from [contractor name] will telephone you in a few days to ask you to take part in a survey. The survey will take only about 10 minutes to complete. Please be assured that [contractor name] will give your answers only to Social Security. They will not use your answers for any other purpose. We will report the survey results by summarizing the answers of everyone who takes the survey.

The interviewers at [contractor name] cannot answer questions about your benefits. If you have any questions about your benefits, please call Social Security toll-free at 1‑800‑772‑1213. If you are deaf or hearing impaired, you may call our TTY number at 1-800-325-0778.

While your participation is voluntary, we hope you will take time to be in the survey because your opinion matters. Your answers and comments will help us serve you better.

Sincerely,

Ronald T. Raborg

Deputy Commissioner for Quality Performance

Social Security Administration

Privacy Act Statement

We are authorized to collect the information for this survey under Executive Order 12862, “Setting Customer Service Standards.” Your response to these questions is strictly voluntary. We will use the information you provide to help us improve the service that we give you. We will not disclose your responses 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 should answer these questions only if 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 10 minutes to complete this survey. This time estimate includes the time it will take to listen to the questions and give your responses. You may send comments on our time estimate to: Social Security Administration, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address.

Sample Notice for Persons with a Special Notice Option of

Braille, Data CD, Audio CD, or Large Print

Date:

We are sending this letter to you in both a standard print version and in the special format that you requested.  You will receive them in separate envelopes.

We would like your help to improve the service we give to blind or visually impaired persons. Our records show that you receive letters from us in a special notice format. We would like to find out if you are satisfied with the special notice format.

An interviewer from [contractor name] will telephone you in a few days to ask you to take part in a survey. The survey will take only about 10 minutes to complete. Please be assured that [contractor name] will give your answers only to Social Security. They will not use your answers for any other purpose. We will report the survey results by summarizing the answers of everyone who takes the survey.

The interviewers at [contractor name] cannot answer questions about your benefits. If you have any questions about your benefits, please call Social Security toll-free at 1‑800‑772‑1213. If you are deaf or hearing impaired, you may call our TTY number at 1-800-325-0778.

While your participation is voluntary, we hope you will take time to be in the survey because your opinion matters. Your answers and comments will help us serve you better.

Sincerely,

Ronald T. Raborg

Deputy Commissioner for Quality Performance

Social Security Administration

Privacy Act Statement

We are authorized to collect the information for this survey under Executive Order 12862, “Setting Customer Service Standards.” Your response to these questions is strictly voluntary. We will use the information you provide to help us improve the service that we give you. We will not disclose your responses 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 should answer these questions only if 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 10 minutes to complete this survey. This time estimate includes the time it will take to listen to the questions and give your responses. You may send comments on our time estimate to: Social Security Administration, 6401 Security Blvd, Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address.