1 Qualitative and 4 Quanatative Surveys

Generic Clearance of Customer Satisfaction Surveys

DICRC Survey Questionnaire and Correspondence

1 Qualitative and 4 Quanatative Surveys

OMB: 0960-0526

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0960-0526 can be found here:

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Disability Initial Claims Report Card - Mid-Process Survey - English

Social Security is committed to improving the service we provide the public. Please complete this
questionnaire to give us your opinion of the service you recently received when you filed for disability benefits.
How did you file your application for disability benefits?
(If you used more than one way, please check the main way.) Mark [X] only ONE.





Did anyone besides Social Security help you with your application? Mark [X] only ONE.

Please tell us who helped you:

Please use the scale shown to rate the following aspects of
your experience filing for disability benefits. If a question
does not apply to you, please mark Not Applicable.
Mark [X] ONE rating for every item.

Not
Applicable





Very Poor



A husband, wife, relative or friend
A state or local government agency (such as your social worker or case worker)
A nonprofit organization that serves people with disabilities
(such as the United Cerebral Palsy Association)
An attorney or a paid professional disability consulting service
A health care provider
Other (such as your employer, school or church)

Poor




Mark [X] all that apply.

Fair

 Go to question 4.
 Go to question 3.

No, I did it by myself with the help of a Social Security employee ONLY.
Yes, I had help from someone other than a Social Security employee.

Good




Very Good

In person with a Social Security employee
Over the telephone with a Social Security employee
On Social Security’s Internet website (www.socialsecurity.gov)
Someone else did it for me

Excellent

N/A

When you decided to file…
4.

Ease of finding information about how to apply for disability
benefits.

N/A

Quality of information you got about how to apply for
disability benefits.

N/A

Ease of working with Social Security to start the application
process.

N/A

PLEASE CONTINUE TO PAGE 2

Explanations Social Security gave you about…
7.

Information and documents you needed for your application.

N/A

Requirements for getting disability benefits and how you
qualify.

N/A

How the disability application process works, for example
who makes the decision

N/A

10. Ease of answering questions about your medical condition
and treatment.

N/A

11. Ease of answering questions about the work you did in the
past.

N/A

12. Ease of answering questions about your education and job
training.

N/A

13. Helpfulness of the staff.

N/A

14. Courtesy of the staff.

N/A

15. How well the staff knew their jobs.

N/A

16. How clearly the staff explained things to you.

N/A

17. The amount of time the staff spent with you.

N/A

18. Ease of filing your disability application with
Social Security.

N/A

19. Overall opinion of Social Security’s service.

N/A

Providing information to Social Security…

How Social Security employees did their job…

Your overall experience…

20. Please use the space below to tell us anything else about the service you received when you filed your
application for disability benefits.

OMB Control Number 0960-0526, Expiration Date: August 2012

Disability Initial Claims Report Card – Post-Adjudicative Survey - English

Social Security is committed to improving the service we provide the public. Please complete this
questionnaire to give us your opinion of the service you received recently when you filed for disability benefits.
1.

How did you file your application for disability benefits?
(If you used more than one way, please check the main way.) Mark [X] only ONE.





In person with a Social Security employee
Over the telephone with a Social Security employee
On Social Security’s Internet Website (www.socialsecurity.gov)
Someone else did it for me

Did anyone besides Social Security help you with your application? Mark [X] only ONE.



3. Please tell us who helped you:




Mark [X] all that apply.

Very Good

Good

Fair

Poor

Very Poor

Not
Applicable

Excellent





 Go to question 4.
 Go to question 3.

No, I did it by myself with the help of a Social Security employee ONLY.
Yes, I had help from someone other than a Social Security employee.

N/A

4. Ease of answering questions about your disability.

N/A

5. Ease of obtaining your own medical records, if you did so.

N/A

6. Experience during any medical examination or test Social
Security sent you to.

N/A

Providing medical information…

PLEASE CONTINUE TO PAGE 2

Finding out what was happening on your application…
7. Ease of contacting Social Security for status of your
application.

N/A

8. Usefulness of information Social Security gave you about the
status.

N/A

9. Helpfulness of the staff.

N/A

10. Courtesy of the staff.

N/A

11. How well the staff knew their jobs.

N/A

12. How clearly the staff explained things to you.

N/A

13. The amount of time the staff spent with you.

N/A

14. Length of time it took Social Security to handle
your application.

N/A

15. Clarity of the letter explaining Social Security’s decision on
your application.

N/A

16. Ease of filing your disability application with
Social Security.

N/A

17. Overall opinion of Social Security’s service.

N/A

How Social Security employees did their job…

Getting the decision on your application…

Your overall experience…

18. Please use the space below to tell us anything else about the service you received when you filed your
application for disability benefits.

OMB Control Number 0960-0526, Expiration Date: August 2012

FY 2012 DICRC SURVEY
PRENOTICE POSTCARD - ENGLISH

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
service you received for your recent business with Social Security.
In a few days, you will receive a short questionnaire in the mail from [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 service.
We look forward to hearing your opinions.
Ronald T. Raborg
Deputy Commissioner for Quality Performance
Social Security Administration

FY 2012 DICRC SURVEY
INITIAL COVER LETTER – ENGLISH

Dear [Insert Name]:
As I noted in my recent postcard, Social Security is conducting a survey to get your opinion of
the service you received when you filed an application for Social Security disability benefits.
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 do not put any information related to
your Social Security business in the envelope with your completed survey.
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. 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 application or benefits, please call Social Security’s tollfree 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 name] can answer questions about your
eligibility or benefits.)
Thank you for sharing your opinions with us.
Sincerely,

Ronald T. Raborg
Deputy Commissioner for Quality Performance
Social Security Administration

FY 2012 DICRC 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
name], who is conducting the survey for us, will be mailing another form to you
shortly.

Thank you for your help with this survey.
Ronald T. Raborg
Deputy Commissioner for Quality Performance
Social Security Administration

FY 2012 DICRC SURVEY
FOLLOW-UP COVER LETTER - ENGLISH

Dear [Insert Name]:
About a month ago we sent you a brief survey asking about the service you received when you
filed an 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.
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
do not put any information related to your Social Security business in the envelope with your
completed survey.
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. 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 application or benefits, please call Social Security’s tollfree 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 name] can answer questions about your
eligibility or benefits.)
We would appreciate receiving your completed survey as soon as possible.
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 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 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.

File Type	application/pdf
File Title	Disability Service Improvement - Mid-Process Survey
Author	dpse
File Modified	2011-07-12
File Created	2011-07-12