665 2013 665 Disability v2

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Overview

Proposed v2 Model Qsts
Current Custom Qsts v2
Current Custom Qsts
Element Rotations

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Sheet 1: Proposed v2 Model Qsts

Model Instance Name:
SSADisability v2
MID:		451pZNUxEwhdwdY1JBg4EA4C
Partitioned No					Element rotation scheme has been added
FPI Included(Y/N)?
NOTE: All non-partitioned surveys will NOT be imputed and the elements will be rotated as a default unless otherwise specified and approved by Research.
Date:		6/12/2013
SSADisability v2
Model questions utilize the ACSI methodology to determine scores and impacts
		ELEMENTS (drivers of satisfaction)			CUSTOMER SATISFACTION			FUTURE BEHAVIORS	FPI
	MQ Label			MQ Label			MQ Label		Y?
		Site Information (1=Poor, 10=Excellent, Don't Know)			Satisfaction			Recommend (1=Very Unlikely, 10=Very Likely)
1	Site Information - Thoroughness	Please rate the thoroughness of information provided in this application.	14	Satisfaction - Overall	What is your overall satisfaction with this application? (1=Very Dissatisfied, 10=Very Satisfied)	17	Recommend	How likely are you to recommend this application to someone else?
2	SiteInformation - Understandable	Please rate how understandable this application’s information is.	15	Satisfaction - Expectations	How well does this application meet your expectations? (1=Falls Short, 10=Exceeds)			Use Other Online Services (1=Very Unlikely, 10=Very Likely)
3	SiteInformation - Answers	Please rate how well the application’s information provides answers to your questions.	16	Satisfaction - Ideal	How does this application compare to your idea of an ideal application? (1=Not Very Close, 10=Very Close)	18	Use Other Online Services	How likely are you to use other Social Security online services?
		Site Performance (1=Poor, 10=Excellent, Don't Know)
4	Site Performance - Consistency	Please rate how quickly pages load in this application.
5	Site Performance - Errors	Please rate the consistency of speed from page to page in this application.
6	leann.hartka: Need label	Please rate the ability to load pages without getting error messages in this application.
		Navigation (1=Poor, 10=Excellent, Don't Know)
7	Navigation - Organized	Please rate how well the application is organized.
8	Navigation - Options	Please rate the options available for navigating this application.
9	Navigation - Layout	Please rate how well the application layout helps you find what you are looking for.
10	Navigation - Clicks	Please rate the number of clicks to get where you want in this application.
		Plain Language (1=Poor, 10=Excellent, Don't Know)
11	Plain Language - Clear	Please rate the clarity of the wording in this application.
12	Plain Language - Understandable	Please rate how well you understand the wording in this application.
13	Plain Language - Concise	Please rate this application on its use of short, clear sentences.

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Sheet 2: Current Custom Qsts v2

Model Instance Name:

red & strike-through: DELETE

SSADisability v2

underlined & italicized: RE-ORDER

MID:

451pZNUxEwhdwdY1JBg4EA4C

pink: ADDITION

Date:

11/1/2010

blue + -->: REWORDING

violet (bold): SKIP-LOGIC

SSADisability v2 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

Labels

LNH5318

How did you hear about the Internet Disability Report?

A Social Security Representative told me about it

A

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Source

Types

From Social Security's website, socialsecurity.gov

Open-ended

Read about it in a Social Security publication

Text Field – limited to 100 characters

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

Text Area – no character limit

Got it from an Internet Search Engine or linked from another website

Dropdown (Select-one)

From a social worker, attorney, or other professional

Radio Button One Up Vertical

Word-of-mouth

Radio Button Two Up Vertical

Other, please specify:

B

Radio Button Three Up Vertical

LNH5319

B

Please specify how you heard about the Internet Disability Report

Text Field – limited to 100 characters

N

Skip Logic Group

OE_How hear about

LNH5320

A

When the representative told you about the Internet Disability Report, did he or she tell you about the Disability Starter Kit?

Yes, the representative gave me a paper Disability Starter Kit.

C

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Rep_Disability Starter Kit

Yes, the representative mailed me a Disability Starter Kit.

C

Yes, the representative told me how to go online and get the Disability Starter Kit.

C

No

Don't know

LNH5321

C

Did the Disability Starter Kit help you complete the online Disability Report?

Yes

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Disability Starter Kit_Help Complete

No

LNH5322

I started filling out the Disability Report because…(Select one)

I am applying for disability benefits for myself

Radio Button One Up Vertical

Single

Y

Skip Logice Group

Fill out Report

Radio Button Scale No Don’t Know

I am helping my husband or wife

Checkbox One Up Vertical

I am helping another relative

Select-multiple Show Two

I am helping a client in my professional capacity

B

I am helping a friend

Select-multiple Show Three

Other, please specify:

A

Select-multiple Show Four

LNH5323

A

Please specify your role in filling out the Disability Report.

Text Field – limited to 100 characters

N

Skip Logice Group

OE_Reason for filling

LNH5324

B

If you are helping a client, what is your role? (Select one)

I am an attorney

Radio Button One Up Vertical

Single

Y

Skip Logice Group

Role in Helping Client

I am a non-attorney representative

I work for an insurance company

I work for a government agency

I work for a not-for-profit organization

I work for a for-profit organization

I work for a hospital, nursing care facility, or health services agency

Other, please specify:

C

LNH5325

C

Please specify your role.

Text Field – limited to 100 characters

N

Skip Logice Group

Role

LNH5326

Did you download, print, or view the Social Security “Disability Benefits Checklist” before starting your Disability Report?

Yes

A

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Disability Starter Kit

No

Don't know what that is

LNH5327

A

Did you find the checklist helpful while completing your application?

Yes

B

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Helpfulness of Checklist

No

Don't know

LNH5328

B

Please rate how helpful the Disability Benefits Checklist was for you.

Extremely helpful

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Rate Helpfulness of Checklist

Very helpful

Moderately helpful

Slightly helpful

Helpful, but barely

Not helpful

LNH5329

Did you finish your Disability Report today?

Yes, I started and finished the report today.

D

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Complete Report

Yes, I finished the report I started before today.

F

No, I did not finish the report but I plan to finish it later.

G

No, I do not plan to come back to finish the report.

A, C

LNH5330

A

Please tell us why you decided not to finish your Disability Report.

Too many questions

Checkbox One Up Vertical

Multi

Y

Skip Logic Group

Why didn't Complete

Takes too long to fill out

Too complicated to use without help

My claim was denied less than 60 days ago

I only had a limited amount of time to spend on it

I was interrupted, for example by family demands

I had problems entering dates or other information

Did not understand what questions meant/how to answer

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

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

Didn’t have information like addresses, dates or doctors’ names readily available

My disabling condition prevents me from working with a computer for long periods

Other, please specify:

B

LNH5331

B

Please tell us why you have stopped working on your Disability Report.

Text Area – no character limit

Skip Logic Group

OE_Reason for stopping

LNH5332

C

How much time did you spend working on your Disability Report before you decided to stop?

Under 1 hour

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Didn't Complete

Between 1 and 2 hours

Between 2 and 3 hours

Between 3 and 4 hours

Between 4 and 5 hours

More than 5 hours

LNH5333

D

How much time did you spend working on your Disability Report today?

Under 1 hour

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Time to Complete

Between 1 and 2 hours

Between 2 and 3 hours

Between 3 and 4 hours

Between 4 and 5 hours

More than 5 hours

LNH5334

F

How much time did you spend all together working on your Disability Report?

Under 1 hour

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Time Spent

Between 1 and 2 hours

Between 2 and 3 hours

Between 3 and 4 hours

Between 4 and 5 hours

More than 5 hours

LNH5335

G

If you chose not to finish your Disability Report in one sitting, please tell us why.

Too many questions

Checkbox One Up Vertical

Multi

Y

Skip Logic Group

OE_Did not finish in one sitting

Takes too long to fill out

Too complicated to use without help

My claim was denied less than 60 days ago

I only had a limited amount of time to spend on it

I was interrupted, for example by family demands

I had problems entering dates or other information

Did not understand what questions meant/how to answer

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

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

Didn’t have information like addresses, dates or doctors’ names readily available

My disabling condition prevents me from working with a computer for long periods

Other, please specify:

H

LNH5336

H

Please specify why you chose not to finish your Disability Report.

Text Area – no character limit

N

Skip Logic Group

OE_Did not finish Report

LNH5337

What is the highest level of education you have completed?

Did not graduate from high school

Dropdown (Select-one)

Single

N

Education

Completed high school or GED

Some college or university courses, but no degree

Bachelor’s degree

Some post-graduate courses

Master’s degree

Doctorate

Prefer not to answer

LNH5338

What is your household income level?

Under $25,000 per year

Dropdown (Select-one)

Single

N

Household Income

$25,000 to $50,000

$50,001 to $75,000

$75,001 to $100,000

$100,001 to $150,000

$150,001 to $200,000

More than $200,000

Prefer not to answer

LNH5339

In addition to completing this Disability Report, did you also fill out Social Security’s Disability Benefit Application online?

Yes

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Disability Application

No

Don't know (please explain)

A

LNH5340

A

Please explain:

Text Area – no character limit

N

Skip Logic Group

OE_Disability Application

LNH5341

Please provide any additional comments about your experience with the Internet Disability Report.

Text Area – no character limit

N

OE_Additional Comments

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Sheet 3: Current Custom Qsts

Model Instance Name:

red & strike-through: DELETE

SSA Disability Report Survey

underlined & italicized: RE-ORDER

MID:

FZdMcl0Ytl0tt9Q4g41s1A==

pink: ADDITION

Date:

11/1/2010

blue + -->: REWORDING

violet (bold): SKIP-LOGIC

SSA Disability Report Survey 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

SVD0025

How did you hear about the Internet Disability Report?

A Social Security Representative told me about it

A

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Types

From Social Security's website, socialsecurity.gov

Open-ended

Read about it in a Social Security publication

Text Field – limited to 100 characters

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

Text Area – no character limit

Got it from an Internet Search Engine or linked from another website

Dropdown (Select-one)

From a social worker, attorney, or other professional

Radio Button One Up Vertical

Word-of-mouth

Radio Button Two Up Vertical

Other, please specify:

B

Radio Button Three Up Vertical

SVD00315

B

Please specify how you heard about the Internet Disability Report

Text Field – limited to 100 characters

N

Skip Logic Group

EDO07615

A

When the representative told you about the Internet Disability Report, did he or she tell you about the Disability Starter Kit?

Yes, the representative gave me a paper Disability Starter Kit.

C

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Yes, the representative mailed me a Disability Starter Kit.

C

Yes, the representative told me how to go online and get the Disability Starter Kit.

C

No

Don't know

EDO07616

C

Did the Disability Starter Kit help you complete the online Disability Report?

Yes

Radio Button One Up Vertical

Single

Y

Skip Logic Group

No

SVD0026

I started filling out the Disability Report because…(Select one)

I am applying for disability benefits for myself

Radio Button One Up Vertical

Single

Y

Skip Logice Group

Radio Button Scale No Don’t Know

I am helping my husband or wife

Checkbox One Up Vertical

I am helping another relative

Select-multiple Show Two

I am helping a client in my professional capacity

B

I am helping a friend

Select-multiple Show Three

Other, please specify:

A

Select-multiple Show Four

SVD00316

A

Please specify your role in filling out the Disability Report.

Text Field – limited to 100 characters

N

Skip Logice Group

EDO07617

B

If you are helping a client, what is your role? (Select one)

I am an attorney

Radio Button One Up Vertical

Single

Y

Skip Logice Group

I am a non-attorney representative

I work for an insurance company

I work for a government agency

I work for a not-for-profit organization

I work for a for-profit organization

I work for a hospital, nursing care facility, or health services agency

Other, please specify:

C

EDO07618

C

Please specify your role.

Text Field – limited to 100 characters

N

Skip Logice Group

SVD00171

Did you download, print, or view the Social Security “Disability Benefits Checklist” before starting your Disability Report?

Yes

A

Radio Button One Up Vertical

Single

Y

Skip Logic Group

No

Don't know what that is

EDO07619

A

Did you find the checklist helpful while completing your application?

Yes

B

Radio Button One Up Vertical

Single

Y

Skip Logic Group

No

Don't know

EDO07620

B

Please rate how helpful the Disability Benefits Checklist was for you.

Extremely helpful

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Very helpful

Moderately helpful

Slightly helpful

Helpful, but barely

Not helpful

SVD0027

Did you finish your disability report today? +--> Did you finish your Disability Report today?

Yes. I started and finished it today. +--> Yes, I started and finished the report today.

D

Radio Button One Up Vertical

Single

Y

Skip Logic Group

SVD0027G5

Yes. I finished the report I started before today. +--> Yes, I finished the report I started before today.

F

No, I did not finish the report but I plan to finish it later.

G

No. I do not plan to come back to finish the report. +--> No, I do not plan to come back to finish the report.

A, C

SVD0029

A

If you do not plan to finish your disability report later, please tell us why. +--> Please tell us why you decided not to finish your Disability Report.

Too many questions

Checkbox One Up Vertical

Multi

Y

Skip Logic Group

Takes too long to fill out

Too complicated to use without help

My claim was denied less than 60 days ago

I only had a limited amount of time to spend on it

I was interrupted, for example by family demands

I had problems entering dates or other information

Did not understand what questions meant/how to answer

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

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

Didn’t have information like addresses, dates or doctors’ names readily available

My disabling condition prevents me from working with a computer for long periods

Other, please specify:

B

SVD00317

B

Please tell us why you have stopped working on your disability report +--> Please tell us why you have stopped working on your Disability Report.

Text Area – no character limit

Skip Logic Group

SVD00319

C

How long did you work on your disability report before stopping? +--> How much time did you spend working on your Disability Report before you decided to stop?

Under 1 hour

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Between 1 and 2 hours

Between 2 and 3 hours

Between 3 and 4 hours

Between 4 and 5 hours

More than 5 hours

SVD00318

D

How much time did you need to fill out your disability report? +--> How much time did you spend working on your Disability Report today?

Under 1 hour

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Between 1 and 2 hours

Between 2 and 3 hours

Between 3 and 4 hours

Between 4 and 5 hours

More than 5 hours

EDO07621

F

How much time did you spend all together working on your Disability Report?

Under 1 hour

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Between 1 and 2 hours

Between 2 and 3 hours

Between 3 and 4 hours

Between 4 and 5 hours

More than 5 hours

EDO07622

G

If you chose not to finish your Disability Report in one sitting, please tell us why.

Too many questions

Checkbox One Up Vertical

Multi

Y

Skip Logic Group

Takes too long to fill out

Too complicated to use without help

My claim was denied less than 60 days ago

I only had a limited amount of time to spend on it

I was interrupted, for example by family demands

I had problems entering dates or other information

Did not understand what questions meant/how to answer

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

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

Didn’t have information like addresses, dates or doctors’ names readily available

My disabling condition prevents me from working with a computer for long periods

Other, please specify:

H

EDO07623

H

Please specify why you chose not to finish your Disability Report.

Text Area – no character limit

N

Skip Logic Group

EDO07624

What is the highest level of education you have completed?

Did not graduate from high school

Dropdown (Select-one)

Single

N

Completed high school or GED

Some college or university courses, but no degree

Bachelor’s degree

Some post-graduate courses

Master’s degree

Doctorate

Prefer not to answer

EDO07625

What is your household income level?

Under $25,000 per year

Dropdown (Select-one)

Single

N

$25,000 to $50,000

$50,001 to $75,000

$75,001 to $100,000

$100,001 to $150,000

$150,001 to $200,000

More than $200,000

Prefer not to answer

EDO07626

In addition to completing this Disability Report, did you also fill out Social Security’s Disability Benefit Application online?

Yes

Radio Button One Up Vertical

Single

Y

Skip Logic Group

No

Don't know (please explain)

A

EDO07627

A

Please explain:

Text Area – no character limit

N

Skip Logic Group

EDO07628

Please provide any additional comments about your experience with the Internet Disability Report.

Text Area – no character limit

N

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Sheet 4: Element Rotations

Base Element Order	Version 2	Version 3	Version 4
Site Information	Plain Language	Navigation	Site Performance
Site Performance	Navigation	Site Information	Plain Language
Navigation	Site Performance	Plain Language	Site Information
Plain Language	Site Information	Site Performance	Navigation
Site Information	Plain Language	Navigation	Site Performance
Site Performance	Navigation	Site Information	Plain Language
Navigation	Site Performance	Plain Language	Site Information
Plain Language	Site Information	Site Performance	Navigation