669 2013 669 ExtraHelp v3 with Spanish Translations

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Overview

English Welcome & ThankYou Text
v3 Model Qsts (EE)
EE v3 Custom Qsts

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Sheet 1: English Welcome & ThankYou Text

Model Instance Name:
SSA Extra Help v2
MID:
Date:	9/15/2011
Welcome and Thank You Text
					Examples
					Current Welcome Text
	Welcome Text
	Thank you for visiting the Social Security Administration (SSA). You have been randomly selected to take part in this survey that is being conducted by ForeSee Results on behalf of SSA. Please take a minute or two to give us your opinions about the Application for Help with Medicare Prescription Drug Plan Costs. The feedback you provide will help SSA enhance its site and serve you better in the future. All results are strictly confidential.
	Thank You Text				Current Thank You Text
	Thank you for your time in completing this survey about the Application for Help with Medicare Prescription Drug Plan Costs. Your input is very valuable will be taken into consideration.
	Invitation Text
					Current Invitation Text
	We'd like your feedback.
	Thank you for visiting the SSA.gov site and using the online application for Help with Medicare Prescription Plan Drug Costs. You have been randomly selected to participate in a customer satisfaction survey to let us know how we can improve your website experience.
	This survey is conducted by an independent company, ForeSee Results.

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Sheet 2: v3 Model Qsts (EE)

Model Instance Name:
SSA Extra Help v3 (English)
MID:		IVsQkEQIoMBUUs049xE45w4C
Partitioned (Y/N)?		N			Element rotation scheme has been added
FPI Included(Y/N)?
Date:		7/19/2013
SSA Extra Help v3 (English)
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?
		Look and Feel (1=Poor, 10=Excellent, Don't Know)			Satisfaction			Recommend (1=Very Unlikely, 10=Very Likely)
	Look and Feel - Appeal	Please rate the visual appeal of the online application for Help with Medicare Prescription Plan Drug Costs.		Satisfaction - Overall	What is your overall satisfaction with the online application for Help with Medicare Prescription Plan Drug Costs? (1=Very Dissatisfied, 10=Very Satisfied)		Recommend	How likely are you to recommend the online application for Help with Medicare Prescription Plan Drug Costs to someone else?
	Look and Feel - Balance	Please rate the balance of graphics and text in the online application for Help with Medicare Prescription Plan Drug Costs.		Satisfaction - Expectations	How well does the online application for Help with Medicare Prescription Plan Drug Costs meet your expectations? (1=Falls Short, 10=Exceeds)			Use Other Applications (1=Very Unlikely, 10=Very Likely)
	Look and Feel - Readability	Please rate the readability of the pages in the online application for Help with Medicare Prescription Plan Drug Costs.		Satisfaction - Ideal	How does the online application for Help with Medicare Prescription Plan Drug Costs compare to your idea of an ideal online application? (1=Not Very Close, 10=Very Close)		Use Other Online Services	How likely are you to use other Social Security online services?
		Site Performance (1=Poor, 10=Excellent, Don't Know)
	Site Performance - Loading	Please rate how quickly pages load in the online application for Help with Medicare Prescription Plan Drug Costs.
	Site Performance - Consistency	Please rate the consistency of speed from page to page in the online application for Help with Medicare Prescription Plan Drug Costs.
	Site Performance - Errors	Please rate the ability to load pages without getting error messages in the online application for Help with Medicare Prescription Plan Drug Costs.
		Plain Language (1=Poor, 10=Excellent, Don't Know)
	Plain Language - Clear	Please rate the clarity of the wording in the Help with Medicare Prescription Plan Drug Costs application.
	Plain Language - Understandable	Please rate how well you understand the wording in the Help with Medicare Prescription Plan Drug Costs application.
	Plain Language - Concise	Please rate the Help with Medicare Prescription Plan Drug Costs application on its use of short, clear sentences.

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Sheet 3: EE v3 Custom Qsts

Model Instance Name:

red & strike-through: DELETE

SSA Extra Help v3 (English)

underlined & italicized: RE-ORDER

MID: IVsQkEQIoMBUUs049xE45w4C

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

Single or Multi

Required Y/N

Special Instructions

CQ Label

BJL2281

Did you complete your application today?

BJL2281A01

Not yet, but I plan to finish today

B-I

Radio

Single

Y

Skip Logic

App Status

Types

BJL2281A02

Yes, I completed my new application today

B-I

Open-ended

BJL2281A03

Yes, I resumed and completed my earlier application

B-I

Text Field – limited to 100 characters

BJL2281A04

No, I did not complete my new application

A, L

Text Area – no character limit

BJL2281A05

No, I did not complete my partial application

A, L

Dropdown (Select-one)

BJL2281A06

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

Radio Button Two Up Vertical

BJL2282

B

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

BJL2282A01

A Social Security Representative told me about it

Radio

Single

Y

Skip Logic

Hear About App

Radio Button Three Up Vertical

BJL2282A02

Saw it on the Social Security Website

Radio Button Scale Has Don’t Know

BJL2282A03

Received a letter about it in the mail from SSA

Radio Button Scale No Don’t Know

BJL2282A04

Read about it in a Social Security publication

Checkbox One Up Vertical

BJL2282A05

Read about it in a Medicare publication

Checkbox Two Up Vertical

BJL2282A06

Saw it on the Medicare website

Checkbox Three Up Vertical

BJL2282A07

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

Select-multiple Show Two

BJL2282A08

Heard about it at my Senior/Community Center

Select-multiple Show Three

BJL2282A09

My doctor, or another professional, told me about it

Select-multiple Show Four

BJL2282A10

Got it from a Search Engine

BJL2282A11

Linked from another website

BJL2282A12

Word-of-mouth

BJL2282A13

Other

BJL2283

D

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

BJL2283A01

Myself

Dropdown (select one)

Single

Y

Skip Logic

App For

BJL2283A02

Myself and my spouse

BJL2283A03

My Spouse

BJL2283A04

My parent

BJL2283A05

My client

BJL2283A06

My relative

BJL2283A07

My friend

BJL2284

A

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

BJL2284A01

Yes

Dropdown (select one)

Single

Y

Skip Logic

Plan to return?

BJL2284A02

No

BJL2285

L

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

BJL2285A01

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?

BJL2285A02

Needed to find documents/other information for my application

BJL2285A03

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

BJL2285A04

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

BJL2285A05

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

BJL2285A06

Received an error message/Kicked off

BJL2285A07

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

BJL2285A08

Didn't have the Reentry Number needed to resume application

BJL2285A09

Application wouldn't accept empty fields

BJL2285A10

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

BJL2285A11

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

BJL2285A12

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

BJL2285A13

Other Reason

BJL2286

G

Please rate your level of experience using the Internet.

BJL2286A01

Very experienced

Radio

Single

Y

Skip Logic

Internet Experience

BJL2286A02

Somewhat experienced

BJL2286A03

Almost no experience

BJL2286A04

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

BJL2287

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

BJL2288

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