473 SSA 473 SSA iClaim v2

Model Instance Name:

red & strike-through: DELETE

SSA iClaim v2 (English Equiv)

underlined & italicized: RE-ORDER

MID: 98cNE5hU0E5gtFMVR8IFUQ==

pink: ADDITION

Date:

7/15/2011

blue + -->: REWORDING

violet (bold): SKIP-LOGIC

SSA iClaim 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

SAC3073

Please rate your impression of the level of security in completing tasks on this application.

1 = Poor

Radio Button Scale Has Don’t Know

Single

Y

Level of Security

2

3

4

5

6

7

8

9

10 = Excellent

Don't know

SAC3074

What type of benefits were you applying for?

Retirement

M, Q, R, X, Y, Z, U, E, W

Dropdown (Select-one)

Single

Y

Skip Logic Group

Type of Benefits

Disability

M, Q, R, X, Y, Z, U, E, G, W

Spouse's

M, Q, R, X, Y, Z, U, E, W

Medicare only

M, Q, R, X, Y, Z, U, E, W

I am not applying today

SAC3075

M

How did you learn about the Social Security online application? (Select all that apply.)

Social Security website

Checkbox One Up Vertical

Multi

Y

Skip Logic Group

Learn About Online App

Types

Friend, spouse, relative, neighbor or acquaintance

Social Security employee

B

Another website or search engine

News (TV, radio, newspaper or Internet)

Advertisement

Social Security statement

Community Group or Association

Other, please specify

A

SAC3076

A

Please specify how you learned of Social Security online.

Text area, no char limit

N

Skip Logic Group

OE_Learn about online app

SAC3077

B

How did you make contact with a Social Security employee?

Visited a local Social Security office

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Contact SSA Employee

Called a local Social Security office

Called the national 800 number

Other, please specify

D

SAC3078

D

Other:

Text field, <100 char

N

Skip Logic Group

OE_Contact SSA Employee

SAC3079

Q

Did you complete your application today?

Yes, I completed my new application today

C

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Complete App

Yes, I restarted and completed my earlier application today

C

No, I did not complete my new application, but I plan to complete it later

C

No, I did not complete my re-started earlier application, but I plan to complete it later

C

No, I do not plan to complete my application at all

C

I'm not applying for benefits today

SAC3080

C

For whom are you filing this online application for Social Security benefits?

Myself

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Whose Behalf

My spouse

My parent

Another relative

My friend

My client

Other

SAC3081

R

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

I finished my application today

Checkbox One Up Vertical

Multi

Y

Skip Logic Group

Why Stopped App

Needed to find documents/other information for my application

Too many questions

Takes too long

Too complicated to use without help

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

Application wouldn't accept empty/blank fields

Received an error message or was "kicked out" of the application

I had a problem entering dates or other information in some of the pages

Other Reason

zz

SAC3082

zz

Please tell us the other reason you stopped working on your application.

Text area, no char limit

N

Skip Logic Group

OE_Stopped Application

SAC3083

X

Did you visit the Social Security home page (www.socialsecurity.gov) today?

Yes

Dropdown (Select-one)

Single

Y

Skip Logic Group

Homepage

No

SAC3084

Y

Did you use the SEARCH box on our website to find what you needed?

Yes

Dropdown (Select-one)

Single

Y

Skip Logic Group

Search

No

SAC3085

Z

Please tell us how easy it was for you to find the application for benefits.

I had little or no difficulty getting to the application

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Find app

I found it somewhat difficult to find the application

Z1

SAC3086

Z1

I found it somewhat difficult to find the application because: (Select all that apply.)

I did not know where to begin looking

Checkbox One Up Vertical

Multi

Y

Skip Logic Group

Difficult to Find

It was not clear to me where the links would lead

The information did not seem to be organized in a logical manner

I used the search function but the results didn’t seem to apply.

Other reason (please describe)

Z2

SAC3087

Z2

Other:

Text area, no char limit

N

Skip Logic Group

OE_Difficult to Find

SAC3088

U

How did you arrive on the Social Security website today?

Typed ssa.gov or socialsecurity.gov into the browser

Dropdown (Select-one)

Single

Y

Skip Logic Group

Arrive

Did a search (i.e. Google, Bing, Yahoo)

Followed a link from medicare.gov

Followed a link from another website

SAC3089

E

Please rate the clarity of the instructions provided for this Social Security online application.

1 = Not At All Clear

F

Radio Button Scale Has Don’t Know

Single

Y

Skip Logic Group

Clarity of Instructions

2

F

3

F

4

F

5

F

6

7

8

9

10 = Very Clear

Don't know

SAC3090

F

What part of the instructions was not clear?

Text area, no char limit

N

Skip Logic Group

OE_Clarity of Instructions

SAC3091

G

Did you complete the Online Disability Report today?

Yes

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Disability Report

No

Don't recall

SAC3092

W

Do you have any other problems with this Social Security Online application that weren't covered in earlier questions, or any suggestions on how we can improve it? (Please do not include any personal information in your answer.)

Text area, no char limit

N

Skip Logic Group

Other Problems

SAC3093

What influenced your decision to use our online benefit application? (Select all that apply.)

I did not want to go to an SSA field office

Checkbox One Up Vertical

Multi

Y

Skip Logic Group

Influenced Decision Benefits

I did not want to do business over the phone

I prefer to use online services as much as possible

I learned about filing online while visiting socialsecurity.gov

Someone from SSA recommended filing online

A friend, relative, or colleague recommended filing online

I knew that if I had a question, I could then call or visit SSA

I am filing on behalf of another person

A

Other, please specify

B

SAC3094

B

Please specify what influenced your decision to file for benefits online.

Text area, no char limit

N

Skip Logic Group

OE_Influenced Decision

SAC3095

A

Please specify your role.

I am a non-profit professional

Radio button, one-up vertical

Single

Y

Skip Logic Group

Role

I am a for-profit professional

I am a friend or relative

Other, please specify

C

SAC3096

C

Other:

Text field, <100 char

N

Skip Logic Group

OE_Role