487 SSA Extra Help 487 SSA Extra Help V2 (English Eqiv)

Model Instance Name:

red & strike-through: DELETE

SSA Extra Help v2 (English Equiv)

underlined & italicized: RE-ORDER

MID: QsRVQ5o0Z8FxQtc4JBwJkg==

pink: ADDITION

Date:

9/15/2011

blue + -->: REWORDING

violet (bold): SKIP-LOGIC

SSA Extra Help v2 (English Equiv) CUSTOM QUESTION LIST

QID

Skip Logic Label

Question Text

Answer Choices (limited to 50 characters)

Skip to:

Type (select from list)

Single or Multi

Required Y/N

Special Instructions

CQ Label

SAC4054

Did you complete your application today?

SAC4054A001

Not yet, but I plan to finish today

B-I

Dropdown (Select-one)

Single

Y

Skip Logic

App Status

Types

SAC4054A002

Yes, I completed my new application today

B-I

Open-ended

SAC4054A003

Yes, I resumed and completed my earlier application

B-I

Text Field – limited to 100 characters

SAC4054A004

No, I did not complete my new application

A, L

Text Area – no character limit

SAC4054A005

No, I did not complete my partial application

A, L

Dropdown (Select-one)

SAC4054A006

I'm not applying for Help with Medicare Prescription Plan Drug Costs today

Radio Button Two Up Vertical

SAC4055

B

How did you first hear about the on-line Application for Help with the Medicare Prescription Plan Drug Costs?

SAC4055A001

A Social Security Representative told me about it

Dropdown (Select-one)

Single

Y

Skip Logic

Hear About App

Radio Button Three Up Vertical

SAC4055A002

Saw it on the Social Security Website

Radio Button Scale Has Don’t Know

SAC4055A003

Received a letter about it in the mail from SSA

Radio Button Scale No Don’t Know

SAC4055A004

Read about it in a Social Security publication

Checkbox One Up Vertical

SAC4055A005

Read about it in a Medicare publication

Checkbox Two Up Vertical

SAC4055A006

Saw it on the Medicare website

Checkbox Three Up Vertical

SAC4055A007

Saw it in a newspaper, magazine, television or other media source

Select-multiple Show Two

SAC4055A008

Heard about it at my Senior/Community Center

Select-multiple Show Three

SAC4055A009

My doctor, or another professional, told me about it

Select-multiple Show Four

SAC4055A010

Got it from a Search Engine

SAC4055A011

Linked from another website

SAC4055A012

Word-of-mouth

SAC4055A013

Other

SAC4056

C

Did you use the Find Out If You Qualify option before you entered the on-line Help with Medicare Prescription Drug Plan Costs application?

SAC4056A001

Yes

M

Dropdown (Select-one)

Single

Y

Skip Logic

Find Out If You Qualify

SAC4056A002

No

SAC4056A003

I don't know what that is

SAC4057

M

Was the Find Out If You Qualify option helpful in making your decision to apply for help?

SAC4057A001

Yes, it was helpful in making my decision

Dropdown (Select-one)

Single

N

Skip Logic

Qualify Helpful?

SAC4057A002

No, I thought it was not helpful

SAC4057A003

I did not use the Find Out If You Qualify option

SAC4058

D

For whom are you completing the on-line Help with Medicare Prescription Drug Plan Costs application?

SAC4058A001

Myself

Dropdown (Select-one)

Single

Y

Skip Logic

App For

SAC4058A002

Myself and my spouse

SAC4058A003

My Spouse

SAC4058A004

My parent

SAC4058A005

My client

SAC4058A006

My relative

SAC4058A007

My friend

SAC4059

A

If you have decided to stop working on your application for now, do you plan to return to complete it later?

SAC4059A001

Yes

Dropdown (Select-one)

Single

Y

Skip Logic

Plan to return?

SAC4059A002

No

SAC4060

L

If you stopped working on your application, please tell us why: (Select all that apply)

SAC4060A001

I'm not applying for Help with Medicare Prescription Plan Drug Costs today

Checkbox One Up Vertical

Multi

Y

Skip Logic

Why did you stop?

SAC4060A002

Needed to find documents/other information for my application

SAC4060A003

Too complicated/Takes too long/Too many questions to answer without help

SAC4060A004

My medical/physical condition prevents me from working on the computer for long periods

SAC4060A005

I don't have the necessary computer skills to complete the application

SAC4060A006

Received an error message/Kicked off

SAC4060A007

Tried to use my Reentry Number to resume my application, but it wouldn't work

SAC4060A008

Didn't have the Reentry Number needed to resume application

SAC4060A009

Application wouldn't accept empty fields

SAC4060A010

I had problem(s) entering information in some of the pages

SAC4060A011

I made a mistake on one of the screens, but couldn't correct it

SAC4060A012

I was working on my application when the site shut down for the night

SAC4060A013

Other Reason

SAC4061

G

Please rate your level of experience using the Internet.

SAC4061A001

Very experienced

Dropdown (Select-one)

Single

Y

Skip Logic

Internet Experience

SAC4061A002

Somewhat experienced

SAC4061A003

Almost no experience

SAC4061A004

Filing for Extra Help for Prescription Costs online is the first I’ve used the Internet.

SAC4062

H

If you answered you heard about the on-line Application for Help with Medicare Prescription Plan Drug Costs from another website or a search engine, please tell us which one:

Text Area – no character limit

N

Skip Logic

OE_heard about

SAC4063

I

Do you have any problems with, or specific suggestions to improve, this on-line Application for Help with Medicare Prescription Plan Drug Costs? (Please do not include any personal information in your answer.)

Text Area – no character limit

N

Skip Logic

OE_Problems