1 Qualitative and 4 Quanatative Surveys

Give Social Security a Report Card...
Please answer the following questions to give us your opinion of the online application you recently
completed Social Security’s website.
MARKING INSTRUCTIONS
Correct Marking Example: 
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Use blue or black pen or a number 2 pencil.
Do not use pens with ink that soaks through the paper.

1.

How did you hear about Social Security’s online application?
Mark all that apply.

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Make no stray marks.
Keep all entries within the boxes.

From Social Security (an employee, their website, written material, etc.)
From a family member or friend
From an Internet search engine or website other than Social Security’s
From online social media (Facebook, Twitter, etc.)
From traditional media (newspaper, magazine, TV or radio, etc.)
From a doctor or other health care professional, social worker
From a nonprofit organization that serves the aged or people with disabilities (United Cerebral
Palsy, ARC, etc.)

□ From an attorney or a paid professional consulting service (Allsup, Binder & Binder, etc.)
□ Somewhere else (employer, union, school, church, etc.)
2.

Did you fill out the online application by yourself or was someone else there to help you with it?
Mark only ONE answer.

□ Filled it out by myself
→Please skip to question 4.
□ Someone else helped me →Please continue with question 3.
3. Who helped you?
Mark only ONE answer.

□ Non-professional (family member, friend, etc.)
□ Professional (attorney, social worker, doctor, etc.)

Good

Fair

Poor

Very Poor

Not
Applicable

When You Decided to File Online…
4. Ease of finding the online application on Social Security’s
website
5. Number of pages you went through before you could start the
online application
6. Appearance of the online application pages (amount of
information, how the information is arranged, etc.)
7. How well Social Security’s website explained what information
and documents you needed to complete your online application
Completing the Online Application…

Very Good

Mark [X] ONE answer for every item.

Excellent

Please use the scale shown to rate the following aspects of your experience using Social Security’s online
application. If a question does not apply to you, please mark Not Applicable.

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8.

Ease of answering the questions on the online application

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9.

Helpfulness of the explanations in the “More Info” links on the
online application

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Please continue to the next page

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Excellent

Very Good

Good

Fair

Poor

Very Poor

Not
Applicable

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15. The security and privacy features of the website

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Your Overall Rating…
16. Overall opinion of Social Security’s online
application

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Mark [X] ONE answer for every item.

10. Availability of help from Social Security to complete the online
application
11. Length of time it took to complete the online
application
12. About how long did it take you complete the online application?
Mark only ONE answer.

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15 minutes or less
Over 15 and up to 30 minutes
Over 30 and up to 45 minutes
Over 45 and up to 1 hour
Over 1 hour and up to 2 hours
More than 2 hours

Very
Likely

Somewhat
Likely

Not very
Likely

Not at all
Likely

Not
Applicable

Explanations on Social Security’s Website about…
13. What would happen after you submitted your
online application
14. Other information you needed to know about
your benefits

17. Recommend Social Security’s online application to others

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18. Use Social Security’s website for your future business (request
information, change your address, etc.)
Your Need for Special Accommodations…

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Mark [X] ONE answer for every item.

Your Likelihood to…

19. When you do business with Social Security, in person, on the telephone, or online, do you need them to
provide any special accommodations because of a medical condition?
Mark [X] only ONE answer.
(Answer question 20 and tell us what special accommodations you need in question 21.)

Not
Applicable

Very
Dissatisfied

Somewhat
Dissatisfied

Mark [X] only ONE answer.

Somewhat
Satisfied

(Skip to question 21.)
Very
Satisfied

□ Yes
□ No

20. How satisfied are you with how well Social Security meets your
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need for special accommodations?
21. Please use this space to provide any comments you may have about Social Security’s online application or to
explain any of your answers.

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

Thank you for taking the time to rate Social Security!
Please send us your “Report Card” in the enclosed postage-paid envelope as soon as possible.

Give Social Security a Report Card...
Please answer the following questions to give us your opinion of the change of address or direct deposit
service you recently used on Social Security’s website.
MARKING INSTRUCTIONS
Correct Marking Example: 
•
•
1.

• Make no stray marks.
• Keep all entries within the boxes.
How did you hear about the change of address or direct deposit service on Social Security’s website?
Mark [X] all that apply.
Use blue or black pen or a number 2 pencil.
Do not use pens with ink that soaks through the paper.

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2.

From Social Security (an employee, their website, written material, etc.)
From a family member or friend
From an Internet search engine or website other than Social Security’s
From online social media (Facebook, Twitter, etc.)
From traditional media (newspaper, magazine, TV or radio, etc.)
From a bank or financial institution
Somewhere else (employer, school, church, etc.)

Did you complete the online request for a change of address or direct deposit by yourself or was someone
else there to help you?
Mark [X] only ONE answer.

□ Completed it by myself
□ Someone else helped me
3.

→ Please skip to question 4.
→ Please continue with question 3.

Who helped you?
Mark [X] only ONE answer.

□ Non-professional (family member, friend, etc.)
□ Professional (bank employee, attorney, social worker, etc.)
4.

To protect your personal information Social Security requires you to confirm your identity when you use the
online change of address or direct deposit service. How did you confirm your identity?
Mark [X] only ONE answer.

□ I requested a numeric password to report my change →
□ I used a numeric password I already had
→
□ I did not use a numeric password; I answered personal

Please continue with question 5.
Please skip to question 6.

Excellent

Very Good

Good

Fair

Poor

Very Poor

Not
Applicable

Please skip to question 6.
information questions (date and place of birth, etc.)
Please use the scale shown to rate the following aspects of your experience using Social Security’s online
change of address or direct deposit service. If a question does not apply to you, please mark
Not Applicable.

5.

Ease of obtaining a password to use Social Security’s change
of address or direct deposit service

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6.

Ease of finding the change of address or direct deposit
service on Social Security’s website

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7.

Number of pages you went through before you could start the
change of address or direct deposit report

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8.

Appearance of the online pages (amount of information, how
the information is arranged, etc.)

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9.

How well Social Security’s website explained what
information you needed to complete your report

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Mark [X] ONE answer for every item.

When You Decided to Report Your Change Online…

Please continue to the next page

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Good

Fair

Poor

Very Poor

Not
Applicable

13. Length of time it took to complete your report

Very
Good

Completing the Online Report…
10. Ease of answering the questions for your change of address
or direct deposit report
11. Helpfulness of the explanations and examples about how to
complete your report
12. Availability of help from Social Security to complete your
report

Excellent

Mark [X] ONE answer for every item.

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14. About how long did it take you to complete your change of address or direct deposit report online?
Mark [X] only ONE answer.

□ 10 minutes or less
□ Over 10 and up to 20 minutes
□ More than 20 minutes
Information from Social Security …

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16. Explaining how they will process your report

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17. Explaining the security and privacy features of the website

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Your Overall Rating…
18. Overall opinion of Social Security’s online change of address
or direct deposit service

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Not
Applicable

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Not at all
Likely

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Not very
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Somewhat
Likely

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Very
Likely

15. Confirming that they received your report

19. Recommend Social Security’s website to others

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20. Use Social Security’s website for your future business
(request information, report a change, etc.)
Your Need for Special Accommodations…

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Mark [X] ONE answer for every item.

Your Likelihood to…

21. When you do business with Social Security, in person, on the telephone or online, do you need them to
provide any special accommodations because of a medical condition?
Mark [X] only ONE answer.
(Answer question 22 and tell us what special accommodations you need in question 23.)

22. How satisfied are you with how well Social Security meets your
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need for special accommodations?
23. Please use this space to provide any comments you may have about Social Security’s online change of
address or direct deposit service or to explain any of your answers.

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

Thank you for taking the time to rate Social Security!
Please send us your “Report Card” in the enclosed postage-paid envelope as soon as possible.

Not
Applicable

Very
Dissatisfied

Somewhat
Dissatisfied

Mark [X] only ONE answer.

Somewhat
Satisfied

(Skip to question 23.)
Very
Satisfied

□ Yes
□ No

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Give Social Security a Report Card...
Please answer the following questions to give us your opinion of the online Disability Report you recently
completed on Social Security’s website for an application for disability benefits or request for an appeal.
MARKING INSTRUCTIONS
Correct Marking Example: 
•
•
1.

•
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How did you hear about completing the Disability Report online?
Mark all that apply.
Use blue or black pen or a number 2 pencil.
Do not use pens with ink that soaks through the paper.

□
□
□
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□
□
□

Make no stray marks.
Keep all entries within the boxes.

From Social Security (an employee, their website, written material, etc.)
From a family member or friend
From an Internet search engine or website other than Social Security’s
From online social media (Facebook, Twitter, etc.)
From traditional media (newspaper, magazine, TV or radio, etc.)
From a doctor or other health care professional, social worker
From a nonprofit organization that serves the aged or people with disabilities (United Cerebral
Palsy, ARC, etc.)

□ From an attorney or a paid professional consulting service (Allsup, Binder & Binder, etc.)
□ Somewhere else (employer, union, school, church, etc.)
2. Did you fill out the online Disability Report by yourself or was someone else there to help you with it?
Mark only ONE answer.

□ Filled it out by myself
□ Someone else helped me

Excellent

Very Good

Good

Fair

Poor

Very Poor

Not
Applicable

Please use the scale shown to rate the following aspects of your experience using Social Security’s online
Disability Report. If a question does not apply to you, please mark Not Applicable.

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Number of pages you went through before you
could start the online Disability Report

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How well Social Security’s website explained how
the online Disability Report works
6. How well Social Security’s website explained
what information you needed to complete the
online Disability Report
7. Appearance of the online Disability Report pages
(amount of information, how the information is
arranged, etc.)
Completing the Online Disability Report …

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Mark [X] ONE answer for every item.

Starting the Online Disability Report…
3. Ease of finding the online Disability Report on
Social Security’s website
4.
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8.

Did you complete the online Disability Report in one or more than one sitting?
Mark only ONE answer.

□ One sitting
□ More than one sitting

Please skip to question 10.
Please continue with question 9.

9.

Ease of getting back to the online Disability
Report you started earlier
10. Length of time it took to complete the online
Disability Report

Please continue to the next page

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11. About how long did it take you complete the online Disability Report?
Mark only ONE answer.
1 hour or less
Over 1 hour and up to 2 hours
Over 2 hours and up to 3 hours

Mark [X] ONE answer for every item.

Very Good

Good

Fair

Poor

Very Poor

Not
Applicable

Over 3 hours
Excellent

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12. Ease of understanding the questions on the online
Disability Report

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13. Ease of providing the information requested on the
online Disability Report

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14. Helpfulness of the examples and explanations in
the links on the online Disability Report

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15. Availability of help from Social Security to
complete the online Disability Report

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16. What would happen after you submitted the online
Disability Report

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17. The security and privacy features of the website

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Your Overall Rating…
18. Overall opinion of Social Security’s online
Disability Report

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Very
Likely

Somewhat
Likely

Not very
Likely

Not at all
Likely

Not
Applicable

Explanations on Social Security’s Website About…

19. Recommend Social Security’s website to others

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20. Use Social Security’s website for future business (look for
information, etc.)

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Mark [X] ONE answer for every item.

Your Likelihood to…

Your Need for Special Accommodations…
21. When you do business with Social Security, in person, on the telephone, or online, do you need them to
provide any special accommodations because of a medical condition?
Mark [X] only ONE answer.
(Answer question 22 and tell us what special accommodations you need in question 23.)

Very
Dissatisfied

Not
Applicable

22. How satisfied are you with how well Social Security
meets your need for special accommodations?

Somewhat
Dissatisfied

Mark [X] only ONE answer.

Somewhat
Satisfied

(Skip to question 23.)
Very
Satisfied

□ Yes
□ No

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23. Please use this space to provide any comments you may have about Social Security’s online Disability
Report or to explain any of your answers.

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

Thank you for taking the time to rate Social Security!
Please send us your “Report Card” in the enclosed postage-paid envelope as soon as possible.

Internet Report Card Survey - Prenotice Postcard

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
business that you (or someone else on your behalf) recently completed on our website.
In a few days, you will receive a short questionnaire in the mail from [insert 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 online
service.
We look forward to hearing your opinions.
Ronald T. Raborg
Deputy Commissioner for Quality Performance
Social Security Administration

Internet Report Card Survey – Initial Cover Letter

RE: [Insert type of online business from sample file]

Dear [Insert name from sample file]:
As I noted in my recent postcard, Social Security is conducting a survey to find out how well we
served you when you (or someone else on your behalf) used our website to complete the business
shown above. Please take 5 minutes to fill out the enclosed "Report Card" and return the form as
soon as possible in the postage-paid envelope provided. 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.
If you have a question about Social Security benefits, please visit our web site at
www.socialsecurity.gov or call our toll-free information line at 1-800-772-1213. (To protect
your privacy, my staff cannot answer questions about your eligibility or benefits.)
We appreciate your taking time out of your busy schedule to answer our survey.
Sincerely,

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

Internet Report Card Survey – Privacy Act

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.

Internet Report Card Survey – Follow-up Cover Letter

RE: [Insert type of online business from sample file]

Dear [Insert name from sample file]:
About a week ago we sent you a survey form, “Give Social Security a Report Card,” to find out
how well we served you when you (or someone else on your behalf) used our website to
complete the business shown above. We haven’t yet heard from you and it’s important that we
gather opinions from as many people as possible. If you have already 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 had time to fill out and return your survey, please take a few
minutes right now to do that. The form is short and takes less than 5 minutes to complete. In
case you misplaced the survey, 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.
If you have a question about Social Security benefits, please visit our web site at
www.socialsecurity.gov or call our toll-free information line at 1-800-772-1213. (To protect
your privacy, my staff cannot 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
Enclosures