Disability Access and Functional Needs Representative Survey

Disability Access and Functional Needs Representative Survey

FEMA Form 007-0-8

OMB No.: 1660-0036

Expires:

Public reporting burden for this survey is estimated to average 7 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the survey. You are not required to respond to this collection of information unless it displays a valid OMB control number near the title of the electronic collection instrument, or for on-line applications, on the first screen viewed by the respondents. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (1660-0036) NOTE: Do not send your completed form to this address.

The following survey is voluntary.

Hello, I’m calling from FEMA, the Federal Emergency Management Agency. My name is ___________. My I. D. # is ______. May I please speak with ____________________(applicant name) or the person who received a call from FEMA?

If no: Thank you for your time and have a good evening. (Mark Attempt)

If yes: We’re looking for ways to improve the quality of our service and your opinion is very important to us. Do you remember speaking with ___________ (name of Representative –Caseworker)?

If no, Mark Attempt as Do Not Remember: Thank you for your time and have a good day/evening.

If yes: Would you volunteer to take 5-7 minutes to answer some questions?

• No (if no) I understand, Thank you for your time and have a nice day/evening)

• Yes (if yes) Thank you. The following questions have been approved by the Office of Management and Budget under number 1660-0036. Please be assured your answers will not affect the outcome of your application for FEMA assistance.

DISABILITY ACCESS AND FUNCTIONAL NEEDS – Data provided by JFO Disability Coordinator based on “yes” response to NEMIS RI question about Support Loss for ACCESS AND FUNCTIONAL NEEDS: "Did you, your spouse, or any dependents have help or support doing things like walking, seeing, hearing, speaking, or taking care of yourself before the disaster and have you lost that help or support because of the disaster?” A “yes” response indicates the applicant had help or support and have lost that help or support because of the disaster including the following: Mobility, Hearing/Speech, Intellectual/Cognitive/Mental Health, Vision and Other. OR Data provided by Disability Coordinator when disaster specific needs are identified; such as, or Community Relations, DRC, ISC, EOC or another Agency identifies a need, or the Long Term Recovery Committee has exhausted all resources.
QUESTION		RESPONSE
AFN#1	Let’s start with questions about the telephone call that you received. How would you rate (the Caseworker) on showing an interest in helping you? Would you say he/she (the Caseworker) was… (If Below Average or Poor go to 1a Otherwise go to 2)	Excellent Good Satisfactory Below Average Poor DO NOT READ * Do not know/no opinion
AFN#1a	What made you feel he/she was not interested in helping? (NOTE: Do not read the list, listen and mark all that apply)	Rushed through call Didn’t answer questions I had to repeat questions Didn’t express empathy Didn’t make me eligible Could not help with appeal/reconsideration Didn’t have an understanding of my access or functional needs Other (specify):

Disability Access and Functional Needs
QUESTION		RESPONSE
AFN#2	How would you rate him/her (the Caseworker) on providing information in an easy to understand manner? Would you say… (If Below Average or Poor go to 2a If Excellent go to 2b Otherwise go to 3)	Excellent Good Satisfactory Below Average or Poor DO NOT READ * Do not know/no opinion
AFN#2a	In what way was it below average or poor? (NOTE: Do not read the list, listen and mark all that apply.)	Used government jargon Spoke too fast Terms unclear Information un clear Next steps not given Too much information Too complicated Not enough time to write it down Didn’t answer my questions Didn’t provide accessible communication options to me Other (Specify) Other (Specify)
AFN#2b	What specifically did (he/she) do to help you understand the information?	Patient Used Easy Terminology Asked if I Understood Repeated Information Other (Specify
AFN#3	How would you rate him/her on being courteous? Would you say… (If Below Average or Poor go to 3a Otherwise go to 4)	Excellent Good Satisfactory Below Average Poor DO NOT READ Do not know/No opinion

AFN#3A	In what way was he/she not courteous? Note: Do not read the list, listen and mark all that apply.)	Spoke too fast Tone of voice Condescending Accusatory Impatient Other (Specify)
AFN#4	How would you rate him/her on letting you know what you needed to do next? (If Below Average or Poor go to 4a Otherwise go to 5)	Excellent Good Satisfactory Below Average Poor Do not know/No opinion
AFN# 4a	In what way was it Below Average/Poor? Note: Do not read the list, listen and mark all that apply.)	Information not clear Next steps not given Too much information Too complicated Not enough time to write it down Didn’t answer my questions Could not contact the Rep to ask additional questions Other (Specify)
AFN#5	How confident were you that he/she would handle your needs satisfactorily? Would you say you were Extremely Confident, Very Confident, Somewhat Confident, Not Very Confident, or Not at all Confident? (If Not Very Confident or Not At All Confident go to 5a If Extremely Confident go 5b Otherwise go to 6)	Extremely Effective Very Effective Somewhat Effective Not Very Effective Not At All Effective I had no issues Do not know/No opinion

AFN#5	What specifically caused you to feel Not Very Confident / Not at all Confident? (Note: Do not read the list, listen and mark all that apply.)	Inconsistent information Didn’t answer my question Didn’t trust agent No confidence in information Took too long Too complicated Could not contact the Rep to ask additional question
AFN#5b	What specifically caused you to feel Extremely Confident?	Provided valuable information Answered questions Instilled confidence Quick but didn’t rush Other (specify)

Disability Access and Functional Needs
QUESTION		RESPONSE
AFN#6	Overall, how would you rate the level of customer service provided by _____ (the Caseworker)? Would you say it was… (If Below Average or Poor go to 6a Otherwise go to 7)	Excellent Good Satisfactory Below Average Poor Do not know/No opinion
AFN#6a	What could he/she have done better? (Enter in text box exactly as stated by applicant)	(Text)
AFN#7	During this call, were you referred to another agency (or agencies) for any help? (If yes, go to 7a If No go to 8)	Yes Which one(s)? (#1___, #2____, #3_____) (Use of JFO database will provide this answer.) No
AFN#7a	Did you contact that agency (those agencies)? (If yes, go to 7b If No go to 8)	Yes (#1___, #2____, #3_____) No Tried but was not able to(#1___, #2____, #3_____) Decided not to (#1___, #2____, #3_____) Do not Remember

Disability Access and Functional Needs CUSTOM QUESTION
QUESTION		RESPONSE
AFN#7b	If yes to #7a. For the 1st Agency: How would you rate the overall help provided by ________ (agency)? Would you say they were… (If Below Average or Poor go to 7c Otherwise go to 8)	Excellent Good Satisfactory Below Average or Poor Do not know/No opinion
AFN#7c	In what way was the help below average/poor? (If only 1 agency stated, skip #7d,7e,7f,and 7g and go to 8)	They had no program Didn’t qualify for assistance Insufficient assistance Process was too complicated Took too long to receive assistance Rep was not knowledgeable Rep had poor customer service Other:
AFN#7d	For the 2nd Agency you were referred to: How would you rate the overall help provided by ________ (agency)? (If Below Average or Poor go to 7e Otherwise go to 8)	Excellent Good Satisfactory Below Average or Poor Do not know/No opinion
AFN#7e	In what way was the help below average/poor?	They had no program Didn’t qualify for assistance Insufficient assistance Process was too complicated Took too long to receive assistance Rep was not knowledgeable Rep had poor customer service Other:

Disability Access and Functional Needs CUSTOM QUESTION
QUESTION		RESPONSE
AFN#7f	For the 3rd Agency: How would you rate the overall help provided by ________ (agency)? (If Below Average or Poor go to 7c Otherwise go to 8)	Excellent Good Satisfactory Below Average or Poor Do not know/No opinion
AFN#7g	In what way was the help below average/poor?	They had no program Didn’t qualify for assistance Insufficient assistance Process was too complicated Took too long to receive assistance Rep was not knowledgeable Rep had poor customer service Other:
AFN#8	Were your expectations of the Caseworker: (Read List) If not met go to 8a	Exceeded Met or Not Met
AFN#8a	In what way were they not met?	Specify: Text Box

SUGGESTIONS TO IMPROVE
Question		Response Options
9. FEMA is interested in getting your opinion on what we could do to improve our service. What other suggestions would you like to pass on to FEMA about customer service that you haven’t already shared? (Clarify all vague responses. Probe once with “WHAT OTHER SUGGESTIONS?”)		Open-ended Question Type response in designated area. ________________________________________________________________________________________________________________________________________________________

CLOSING
Call back: Your opinion is very valuable to us, may we call you at a later date to ask you some additional questions? Yes (If “yes”) Thank you very much for your time. Have a good day/evening. No (If “no”) I understand. Thank you very much for your time. Have a good day/evening.

FEMA Form 007-0-8 Page 11 of 11