Form G-201 Customer Assessment Survey

Your opinions are very important to us.
By completing this customer assessment
survey, we will be better able to evaluate
and improve our level of service.

Did you have an appointment before
visiting the office?

City:

The purpose of my visit was:

-Yes

No

(check all that apply)

Date:
Time:
Please rate the following items by placing a check mark on the line that best
describes your experience.

Upon entering the office, I was greeted:
in a very friendly manner

-

unemployment benefits or questions

-

sickness benefits or questions

- placement services
-

in a n unfriendly manner

I was not greeted
Overall, the employees were:
- very professional
professional

railroad service/compensation records
pre-retirement information

- retirement benefit application
-

- in a moderately friendly manner

-

Are there any additional comments
you wish to share about your visit?

Are there any suggestions on how we
could improve our 'levelof service?

survivor benefit application

- Medicare application or question
income tax information
- other

(specify)

I received the information/service
I was seeking.
-Yes

-No

(specify)

OFTIONAL

unprofessional (specify)
Name:

The overall quality of service was:
My visit lasted about:
15 minutes or less

- 16 to 30 minutes
-

31 minutes to 1hour
over 1hour

-outstanding
-very good
average
-poor
very poor

Paperwork Reduction and Privacy Act Notice
The Railroad Retirement Board (RRB) i s authorized to collect the information requested
on this form under Section 7b(6) of t h e Railroad Retirement Act (RRA) and Section 5(b) of
the Railroad Unemployment Insurance Act (RUIA). The information is needed so that the
RRB can determine your opinion a s to the quality of its services to you with respect to
your application or claim for RRA/RUIA benefits a n d general inquiries you may have
made with the RRB. Although you a r e not required to provide the requested information,
your cooperation i n doing so will assist the RRB in its continuing efforts to provide the
public with timely and high quality service.

Address:
Phone: (

)

Simply fold, tape, and drop in any mailbox.
This survey has been postage paid for your
convenience.

We estimate this form takes a n average of 2 minutes per response to complete, including the
time required for reviewing the instructions, getting the needed data, a n d reviewing the
completed form. Federal agencies may not conduct or sponsor, a n d respondents a r e not
required to respond to, a collection of information unless i t displays a valid OMB number. If
you wish, send comments regarding the accuracy of our time estimate for this form, including suggestions for reducing completion time, to Chief of Information Resources Management,
Railroad Retirement Board, 844 North Rush Street, Chicago, Illinois 60611-2092.

Customer-driven
Quality Service
Is Our Top Pdoriiy
Dear Customer:
Our goal is to provide you the
efficient, friendly service you
deserve. Please take a moment to
tell us how our office served you.
If our office did not meet your
expectations, we want to hear about
it. Likewise, if you received excellent service, we want to hear that
too so that we can commend our
employees for a job well done.
Your comments and suggestions
allow us to improve our level of
service. Our top priority is you, the
customer. We want to make sure
you are pleased with the service
you receive.
Sincerely

Michael S. Sch wartz
Chairman

V. M. Speakman, Jr.
Labor Member

Jerome E. Kever
Management Member

Form Approved

OMB NO. 3220-0192