EN Customer Satisfaction Survey

OMB Control No. 0960-0526

Expiration Date: June 2012

CONSUMER SATISFACTION SURVEY

YOUR HELP IS VERY IMPORTANT! This survey has been mailed to Social Security Administration beneficiaries who have assigned their tickets to an Employment Network under the Ticket to Work program. The questions below will be used to provide information on Employment Networks. Your Employment Network is <INSERT FIELD>. The Employment Network’s staff will not see your answers.

Please answer every question. If you are not sure of an exact answer, for example, how many hours you work per week, please give your best guess.

If you would prefer to complete the survey online, instead of on paper, please go to:

www.URLaddress.com

You will be asked for a PIN number. Your PIN number is <INSERT FIELD>

If you have any questions about this survey, you may contact (Insert Name of EurekaFacts account representative) of EurekaFacts at (Insert phone number).

Thank you very much for your help in improving the Ticket to Work program.

_______________________________________________________________________________________________________

Paperwork Reduction Act Statement

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 display a valid Office of Management and Budget control number. We estimate that it will take about 10 minutes to complete this survey. You may send comments on our time estimate above: SSA, 6401 Security Blvd., Baltimore, MD  21235-6401. Send only comments relating to our time estimate to this address.

Send the completed questionnaire to:

Ticket to Work Survey

451 Hungerford Drive (Rockville Pike), Suite 515

Rockville, Maryland, 20850

If you completed the survey online, you do not need to send the paper questionnaire.

_______________________________________________________________________________________________________

ABOUT YOUR EMPLOYMENT NETWORK

<INSERT NAME OF EMPLOYMENT NETWORK>

1. Did the Employment Network provide the services you needed?

PLEASE CHECK ONE

___Never

___A few times

___Sometimes

___Usually

___Always

2. Did these services help you meet your individual goals?

PLEASE CHECK ONE

___Never

___A few times

___Sometimes

___Usually

___Always

3. Which of the following services have you received from your Employment Network?

PLEASE CHECK ALL OF THE TYPES OF SERVICES YOU HAVE RECEIVED

__ Job counseling

__ Job readiness

__ Job coaching

__ Job placement

__ Follow-up services after you were working

__ Work incentives counseling or referral for work incentive counseling

__ Help obtaining services from other organizations

__ Other (please specify _______________________________

Please answer the questions below to rate your Employment Network.

4. Helped you understand the type of jobs available in your community

PLEASE CHECK ONE

___Poor

___Fair

___Good

___Very Good

___Excellent

5. Informed you of other agencies in your community that could help you.

PLEASE CHECK ONE

___Poor

___Fair

___Good

___Very Good

___Excellent

__Does not apply

6. Had supportive staff members

PLEASE CHECK ONE

___Poor

___Fair

___Good

___Very Good

___Excellent

7. Provided materials in the format you needed such as Braille, on-line, in print or in another language.

PLEASE CHECK ONE

___Poor

___Fair

___Good

___Very Good

___Excellent

__Does not apply

8. Had staff members who treated you with respect

PLEASE CHECK ONE.

___Poor

___Fair

___Good

___Very Good

___Excellent

9. Had staff members who really knew their job

PLEASE CHECK ONE

___Poor

___Fair

___Good

___Very Good

___Excellent

10. Overall, how would you rate this Employment Network?

PLEASE CHECK ONE

___Poor

___Fair

___Good

___Very Good

___Excellent

11. If you had a friend or family member in a similar situation, would you recommend your Employment Network?

PLEASE CHECK ONE

___Definitely would not recommend

___Probably would not recommend

___Not sure if I would recommend or not

___Probably would recommend

___Definitely would recommend

12. What do you like best about your Employment Network?

PLEASE CHECK ALL THAT APPLY

__The location is convenient

__The respect I received from staff members

__The quality of the services I received from them

__The help they gave me with my job search

__The information they provided about local jobs

__ Information was in a format I could understand

__ Services were available when I needed them

__ Other (please specify) _____________________________________________________

__________________________________________________________________________

13. What do you think your Employment Network needs to improve?

PLEASE CHECK ALL THAT APPLY

__ Find a more convenient location

__ Staff members need to treat consumers with more respect

__ Quality of services needs to be improved

__ Needs to be more effective in helping with job searches

__ Needs better information about local jobs

__ Information needs to be in more accessible formats

__ Have more convenient hours

__ Other (please specify) _____________________________________________________

__________________________________________________________________________

ABOUT YOUR JOB

14. Did you work at a paid job within the last month?

__ No __ Yes

15. Are you currently working?

__ No __ Yes

16 How would you rate the help you received from your Employment Network in getting a job that met your employment goals? If you were working when you assigned your ticket to the Employment Network leave blank.

PLEASE CHECK ONE

___Poor

___Fair

___Good

___Very Good

___Excellent

ANSWER THESE NEXT FOUR QUESTIONS ONLY IF YOU ARE WORKING NOW

17. If you are working, how many hours a week do you normally work at this job?

18. If you are working, does your job offer any of these benefits?

PLEASE CHECK ALL THAT APPLY

__ Paid vacation

__ Paid sick leave

__ Medical insurance

__ Dental insurance

__ Retirement plan

19. Is your job

PLEASE CHECK ONE

___Entry-level skill

___Skilled work

___Technical

___Manager__Professional

___Not sure (If not sure list job title) ________________________________________________________

20. How satisfied are you with your job?

PLEASE CHECK ONE

___Very dissatisfied

___Somewhat dissatisfied

___Somewhat satisfied

___Very satisfied

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