834 2014 834 SSA iClaim2013

American Customer Satisfaction Index (ACSI) E-Government Website Customer Satisfaction Surveys

2014 834 SSA iClaim 2013.xlsx

2014 819 DHS USCIS - 2014 841 VA Medical Centers

OMB: 1090-0008

Document [xlsx]
Download: xlsx | pdf

Overview

Current v3 CQs (EE) (7-23-14)
Current CQs v3 (EN)
Current v3 CQs (SP)
v3 CQs (EE) (7-21-14)
v3 CQs (EE) (7-17-14)
CQs v3 (EN) (7-17-14)
v3 CQs (SP) (7-17-14)
v3 CQs (EE) (6-12-14)
CQs v3 (EN) (6-12-14)
v3 CQs (SP) (6-12-14)
v3 CQs (EE) (12-10-13)
CQs v3 (EN) (12-10-13)
v3 CQs (SP) (12-10-13)
v3 CQs (EE) (8-19-13)
CQs v3 (EN) (8-19-13)
v3 CQs (SP) (8-19-13)


Sheet 1: Current v3 CQs (EE) (7-23-14)

Model Instance Name:

red & strike-through: DELETE





SSA iClaim v3

underlined & italicized: RE-ORDER





MID: xZAAEQw81gIo1Vo4Noc1Rw4C

pink: ADDITION





Date: 7/15/2011 blue + -->: REWORDING








violet (bold): SKIP-LOGIC





SSA iClaim v3 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
BJL2231
What type of benefits were you applying for? Retirement
Dropdown (Select-one) Single Y
Type of Benefits



Medicare only








Disability








Both Retirement and Disability








Spouse's








Other





CAS0045242
Are you applying online for yourself or are you helping someone else? Myself
Dropdown (Select-one) Single Y
Applying for



Helping a Spouse/Relative/Friend








Professional Helping a Client








Other





CAS0045243
How did you learn about this online application? (Select all that apply.) Official Social Security website
check box one up vertical Multi Y Skip Logic Group Learn about App



A general web search (e.g. Google, Bing, etc.)








The radio








The television








An email from Social Security








A newspaper or magazine article








An online ad (Banner/Image)








An online video








A newspaper or magazine ad








A billboard or other printed ad








Social Media (Blog, Facebook, Twitter, etc.)








Friend, spouse, relative, neighbor or acquaintance








Social Security statement








Social Security employee A







Community Group or Association








Other, please specify B




CAS0045244 A How did you make contact with a Social Security employee? Visited a local Social Security office
check box one up vertical Multi Y Skip Logic SSA Emplyee Contact



Called a local Social Security office








Called the national 800 number








Other, please specify AA




CAS0045245 AA Please describe how you made contact with a Social Security employee.

Text box, no char limit
N Skip Logic OPS SSA Employe Contact
CAS0045246 B Please specify how you learned about this online application.

Text box, no char limit
N Skip Logic OPS Learn about App
CAS0045262
Did you use any of the following to prepare to apply online? (Select all that apply.) Reviewed my online Social Security Statement A check box one up vertical Multi Y Skip Logic Prepare for App



I used the Retirement Estimator or other tools on the Social Security website B







I watched the instructional video C







I used other information on the Social Security website to prepare D







I used another resource to prepare to apply online E







I did not use any resources to prepare to apply online





CAS0045263 A How helpful did you find the online Social Security Statement? Very helpful
Drop down select one Single Y Skip Logic Rate Statement



Somewhat helpful








Not at all helpful





CAS0045264 B How helpful did you find the estimator tools on the website? Very helpful
Drop down select one Single Y Skip Logic Rate RE Tools



Somewhat helpful








Not at all helpful





CAS0045265 C How helpful did you find the instructional video? Very helpful
Drop down select one Single Y Skip Logic Rate Video



Somewhat helpful








Not at all helpful





CAS0045266 D How helpful did you find the other information on the Social Security website? Very helpful
Drop down select one Single Y Skip Logic Rate Other Info on Website



Somewhat helpful








Not at all helpful





CAS0045267 E Please describe what other resource(s) you used to prepare to apply online?

Text field, no char limit
N Skip Logic OPS Prepare for App
CAS0045247
Did you start a new online application today or did you return to a saved application? Started a new application
Drop down select one Single Y
App Status



Returned to work on a saved application





CAS0045282
Did you complete and submit this online application today? Yes
Drop down select one Single Y Skip Logic Complete App



No, I plan to complete and submit later A







No, I do not plan to complete and submit the online application A




CAS0045283 A If you did not complete and submit this online application today, please tell us why. Too many questions
check box one up vertical Multi Y Skip Logic Not Complete App



Takes too long to fill out








Too complicated to use without help








Didn't have information I needed like names, addresses, or dates








Didn't understand what questions meant/how to answer








I wanted to use the Retirement Estimator to reconsider my retirement options








I needed to view my Social Security Statement and/or verify that my earnings record is correct








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








I had a limited amount of time/family demands that kept me from working on it for very long








I had technical problems like an error message or a mistake I couldn't fix








Other, please specify AA




CAS0045284 AA Please tell us why you did not complete and submit this application today.

Text field, no char limit
N Skip Logic OPS Why Not Complete today
CAS0045248
So far, how long have you worked on this online application? Up to 15 minutes
Drop down select one Single Y
Time Spent



16 minutes - 30 minutes








31 minutes - 1 hour








More than 1 hour up to 2 hours








More than 2 hours





CAS0045249
How easy was it for you to find this online application? Very easy




Find App



Somewhat easy








Somewhat hard A







Very hard A




CAS0045250 A Please tell us why it was hard to find the online application. (Select all that apply.) Could not find where to start a new online application
check box one up vertical Multi Y Skip Logic Why hard to find



Not clear where to go to return to a previously saved application








It was not clear to me where the links would lead








Difficulty using a link on the Social Security website








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








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








I tried to use the FAQ's, but couldn't find the online application








Other reason (please describe) AA




CAS0045285 AA Please explain the reason why it was hard for you to find the online application.

N
N Skip Logic OPS Hard to Find
CAS0045286
How did you arrive at this online application today? Used the Online Services link on the Social Security homepage
Radio Button Single Y Skip Logic Arrive at App



Followed a link from somewhere else on the Social Security website








Used the search feature on the Social Security website








Used an outside search engine (i.e. Google, Bing, yahoo etc.)








Followed a link from medicare.gov








Followed a link from another website








Site was bookmarked








Other, please specify A




CAS0045251 A Please describe how you arrived at this online application today

Text field, no char limit
N
OPS Arrive at app
CAS0045252
Why did you choose to apply online? (Select all that apply.) I did not want to go to a local Social Security office
check box one up vertical Multi Y Skip Logic Why Online



I did not want to apply over the phone








I prefer to use online services as much as possible








I learned about applying online while visiting Social Security's website








A Social Security employee recommended that I apply online








A friend or relative recommended that I apply online








I knew that if I had a question or problem applying online, I could still get help from Social Security








I am filing on behalf of another person








Other, please specify A




CAS0045287 A Please specify why you choose to apply online

Text field, no char limit
N
OPS Why Online
CAS0045289
What is your current marital status? Married
Radio button, one-up vertical Single N OPS Group Marital Status


Separated








Divorced                   







Widowed                  







Never married          








Prefer not to answer








Other, please specify A




CAS0045290 A Other marital status

Text field, <100 char
N OPS Group OPS Marital Status
STE0059662
Have you registered for a my Social Security account? Yes
Radio button, one-up vertical Single Y Skip Logic Have mySSA Account



No A




STE0061423 A What is the main reason you have not registered for a my Social Security account? I am unaware of what a my Social Security account is.
Radio button, one-up vertical Single Y Skip Logic Why Not Have mySSA Account



I tried to register for a my Social Security account, but was unsuccessful.








I am currently trying to register for a my Social Security account.








I do not want a my Social Security account.








Other (please specify): AA




STE0061395 AA Please tell us why you have not registered for a my Social Security account.

Text field, no char limit Single N Skip Logic OPS_Why Not Have mySSA Account
CAS0045291
Do you have any suggestions for improving Social Security's online application.

Text field, no char limit
N
OE_Improvement

Sheet 2: Current CQs v3 (EN)

Model Instance Name:

red & strike-through: DELETE





SSA iClaim v3

underlined & italicized: RE-ORDER





MID: VgpBBYx9l8JxIFgJlY1Ikg4C

pink: ADDITION





Date: 7/15/2011 blue + -->: REWORDING








violet (bold): SKIP-LOGIC





SSA iClaim v3 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
ENBJL2231
What type of benefits were you applying for? Retirement
Dropdown (Select-one) Single Y
Type of Benefits



Medicare only








Disability








Both Retirement and Disability








Spouse's








Other





ENCAS0045242
Are you applying online for yourself or are you helping someone else? Myself
Dropdown (Select-one) Single Y
Applying for



Helping a Spouse/Relative/Friend








Professional Helping a Client








Other





ENCAS0045243
How did you learn about this online application? (Select all that apply.) Official Social Security website
check box one up vertical Multi Y Skip Logic Group Learn about App



A general web search (e.g. Google, Bing, etc.)








The radio








The television








An email from Social Security








A newspaper or magazine article








An online ad (Banner/Image)








An online video








A newspaper or magazine ad








A billboard or other printed ad








Social Media (Blog, Facebook, Twitter, etc.)








Friend, spouse, relative, neighbor or acquaintance








Social Security statement








Social Security employee A







Community Group or Association








Other, please specify B




ENCAS0045244 A How did you make contact with a Social Security employee? Visited a local Social Security office
check box one up vertical Multi Y Skip Logic SSA Emplyee Contact



Called a local Social Security office








Called the national 800 number








Other, please specify AA




ENCAS0045245 AA Please describe how you made contact with a Social Security employee.

Text box, no char limit
N Skip Logic OPS SSA Employe Contact
ENCAS0045246 B Please specify how you learned about this online application.

Text box, no char limit
N Skip Logic OPS Learn about App
ENCAS0045262
Did you use any of the following to prepare to apply online? (Select all that apply.) Reviewed my online Social Security Statement A check box one up vertical Multi Y Skip Logic Prepare for App



I used the Retirement Estimator or other tools on the Social Security website B







I watched the instructional video C







I used other information on the Social Security website to prepare D







I used another resource to prepare to apply online E







I did not use any resources to prepare to apply online





ENCAS0045263 A How helpful did you find the online Social Security Statement? Very helpful
Drop down select one Single Y Skip Logic Rate Statement



Somewhat helpful








Not at all helpful





ENCAS0045264 B How helpful did you find the estimator tools on the website? Very helpful
Drop down select one Single Y Skip Logic Rate RE Tools



Somewhat helpful








Not at all helpful





ENCAS0045265 C How helpful did you find the instructional video? Very helpful
Drop down select one Single Y Skip Logic Rate Video



Somewhat helpful








Not at all helpful





ENCAS0045266 D How helpful did you find the other information on the Social Security website? Very helpful
Drop down select one Single Y Skip Logic Rate Other Info on Website



Somewhat helpful








Not at all helpful





ENCAS0045267 E Please describe what other resource(s) you used to prepare to apply online?

Text field, no char limit
N Skip Logic OPS Prepare for App
ENCAS0045247
Did you start a new online application today or did you return to a saved application? Started a new application
Drop down select one Single Y
App Status



Returned to work on a saved application





ENCAS0045282
Did you complete and submit this online application today? Yes
Drop down select one Single Y Skip Logic Complete App



No, I plan to complete and submit later A







No, I do not plan to complete and submit the online application A




ENCAS0045283 A If you did not complete and submit this online application today, please tell us why. Too many questions
check box one up vertical Multi Y Skip Logic Not Complete App



Takes too long to fill out








Too complicated to use without help








Didn't have information I needed like names, addresses, or dates








Didn't understand what questions meant/how to answer








I wanted to use the Retirement Estimator to reconsider my retirement options








I needed to view my Social Security Statement and/or verify that my earnings record is correct








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








I had a limited amount of time/family demands that kept me from working on it for very long








I had technical problems like an error message or a mistake I couldn't fix








Other, please specify AA




ENCAS0045284 AA Please tell us why you did not complete and submit this application today.

Text field, no char limit
N Skip Logic OPS Why Not Complete today
ENCAS0045248
So far, how long have you worked on this online application? Up to 15 minutes
Drop down select one Single Y
Time Spent



16 minutes - 30 minutes








31 minutes - 1 hour








More than 1 hour up to 2 hours








More than 2 hours





ENCAS0045249
How easy was it for you to find this online application? Very easy




Find App



Somewhat easy








Somewhat hard A







Very hard A




ENCAS0045250 A Please tell us why it was hard to find the online application. (Select all that apply.) Could not find where to start a new online application
check box one up vertical Multi Y Skip Logic Why hard to find



Not clear where to go to return to a previously saved application








It was not clear to me where the links would lead








Difficulty using a link on the Social Security website








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








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








I tried to use the FAQ's, but couldn't find the online application








Other reason (please describe) AA




ENCAS0045285 AA Please explain the reason why it was hard for you to find the online application.

N
N Skip Logic OPS Hard to Find
ENCAS0045286
How did you arrive at this online application today? Used the Online Services link on the Social Security homepage
Radio Button Single Y Skip Logic Arrive at App



Followed a link from somewhere else on the Social Security website








Used the search feature on the Social Security website








Used an outside search engine (i.e. Google, Bing, yahoo etc.)








Followed a link from medicare.gov








Followed a link from another website








Site was bookmarked








Other, please specify A




ENCAS0045251 A Please describe how you arrived at this online application today

Text field, no char limit
N
OPS Arrive at app
ENCAS0045252
Why did you choose to apply online? (Select all that apply.) I did not want to go to a local Social Security office
check box one up vertical Multi Y Skip Logic Why Online



I did not want to apply over the phone








I prefer to use online services as much as possible








I learned about applying online while visiting Social Security's website








A Social Security employee recommended that I apply online








A friend or relative recommended that I apply online








I knew that if I had a question or problem applying online, I could still get help from Social Security








I am filing on behalf of another person








Other, please specify A




ENCAS0045287 A Please specify why you choose to apply online

Text field, no char limit
N
OPS Why Online
ENCAS0045289
What is your current marital status? Married
Radio button, one-up vertical Single N OPS Group Marital Status


Separated








Divorced                   







Widowed                  







Never married          








Prefer not to answer








Other, please specify A




ENCAS0045290 A Other marital status

Text field, <100 char
N OPS Group OPS Marital Status
ENSTE0059662
Have you registered for a my Social Security account? Yes
Radio button, one-up vertical Single Y Skip Logic Have mySSA Account



No A




ENSTE0061423 A What is the main reason you have not registered for a my Social Security account? I am unaware of what a my Social Security account is.
Radio button, one-up vertical Single Y Skip Logic Why Not Have mySSA Account



I tried to register for a my Social Security account, but was unsuccessful.








I am currently trying to register for a my Social Security account.








I do not want a my Social Security account.








Other (please specify): AA




ENSTE0061395 AA Please tell us why you have not registered for a my Social Security account.

Text field, no char limit Single N Skip Logic OPS_Why Not Have mySSA Account
ENCAS0045291
Do you have any suggestions for improving Social Security's online application.

Text field, no char limit
N
OE_Improvement

Sheet 3: Current v3 CQs (SP)

Model Instance Name:

red & strike-through: DELETE





SSA iClaim v3 (Spanish)

underlined & italicized: RE-ORDER





MID: Q0ExM1xNQRl9JJUR0M0JlA4C
pink: ADDITION





Date: 7/15/2011 blue + -->: REWORDING








violet (bold): SKIP-LOGIC





SSA iClaim v3 (Spanish) 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
SPBJL2231
¿Qué tipo de beneficios estaba solicitando? Por jubilación
Dropdown (Select-one) Single Y
Type of Benefits



Solo Medicare








Por incapacidad








Tanto Jubilación y Discapacidad








Coomo cónyuge








Otro





SPCAS0045242
¿Es esta solicitud en línea para sí mismo o estás ayudando a alguien más? Yo mismo
Dropdown (Select-one) Single Y
Applying for



Cómo ayudar a un cónyuge / pariente / amigo








Profesional Ayudar a un cliente








Otro





SPCAS0045243
¿Cómo se enteró acerca de esta solicitud en línea? (Seleccione todas las que apliquen.) Sitio web oficial de la Seguridad Social
check box one up vertical Multi Y Skip Logic Group Learn about App



Una búsqueda web general (por ejemplo, Google, Bing, etc)








La radio








La televisión








Un correo electrónico de la Seguridad Social








Un periódico o la revista








Un anuncio en línea (Banner / Imagen)








Un video en línea








Un periódico o una revista de anuncios








Un anuncio impreso cartelera u otro








Medios de Comunicación Social (Blog, Facebook, Twitter, etc)








Amigo, cónyuge, pariente, vecino o conocido








Declaración del Seguro Social








Empleado del Seguro Social A







Grupo de la comunidad o de la Asociación








Otro, especificar B




SPCAS0045244 A ¿Cómo se hace el contacto con un empleado del Seguro Social? Visitado una oficina local del Seguro Social
check box one up vertical Multi Y Skip Logic SSA Emplyee Contact



Llamado a la oficina local del Seguro Social








Llamado el número nacional 800








Otro, especificar AA




SPCAS0045245 AA Por favor describa cómo se hizo contacto con un empleado del Seguro Social.

Text box, no char limit
N Skip Logic OPS SSA Employe Contact
SPCAS0045246 B Por favor, especifique cómo se enteró de esta aplicación en línea.

Text box, no char limit
N Skip Logic OPS Learn about App
SPCAS0045262
¿Ha usado alguna de las siguientes acciones para prepararse para aplicar en línea? (Seleccione todas las que apliquen.) Comentado mi Declaración del Seguro Social en línea A check box one up vertical Multi Y Skip Logic Prepare for App



He utilizado el Retirement Estimator u otras herramientas en el sitio web de la Seguridad Social B







Vi el video de instrucciones C







Usé otra información en la página web de la Seguridad Social para preparar D







Utilicé otro recurso que se preparen para aplicar en línea E







No hice uso de los recursos para prepararse para aplicar en línea





SPCAS0045263 A ¿Qué tan útil ha encontrado el Declaración del Seguro Social en línea? Muy útil
Drop down select one Single Y Skip Logic Rate Statement



algo útil








Para nada útil





SPCAS0045264 B ¿Qué tan útil encontraste las herramientas estimador en el sitio web? Muy útil
Drop down select one Single Y Skip Logic Rate RE Tools



algo útil








Para nada útil





SPCAS0045265 C ¿Qué tan útil le parecen la video instructivo? Muy útil
Drop down select one Single Y Skip Logic Rate Video



algo útil








Para nada útil





SPCAS0045266 D ¿Qué tan útil le parecen la otra información en el sitio web de la Seguridad Social? Muy útil
Drop down select one Single Y Skip Logic Rate Other Info on Website



algo útil








Para nada útil





SPCAS0045267 E Por favor describa lo otro recurso (s) que utilizó para prepararse para aplicar en línea.

Text field, no char limit
N Skip Logic OPS Prepare for App
SPCAS0045247
¿Comenzó una nueva aplicación en línea hoy mismo o que te vuelva a una solicitud guardada? Comenzó una nueva aplicación
Drop down select one Single Y
App Status



Volvió a trabajar en una solicitud guardada





SPCAS0045282
¿Sabía usted completar y presentar esta solicitud en línea hoy en día?
Drop down select one Single Y Skip Logic Complete App



No, tengo la intención de completar y enviar más tarde A







No, no tengo planes para completar y enviar la solicitud en línea A




SPCAS0045283 A Si no logró completar y presentar esta solicitud en línea hoy, por favor díganos por qué. Demasiadas preguntas
check box one up vertical Multi Y Skip Logic Not Complete App



Toma demasiado tiempo para llenar








Demasiado complicado de usar sin ayuda








No tenía la información que necesitaba como nombres, direcciones o fechas








No entendía lo que significaba preguntas / cómo responder








Que quería utilizar el estimador de jubilación reconsiderar mis opciones








Que tenía que ver mi Declaración del Seguro Social y / o comprobar que mi registro de ganancias es el correcto








Mi condición de discapacidad me impide trabajar con una computadora por largos periodos








Yo tenía una cantidad limitada de demandas de tiempo / de la familia que me impedía trabajar en ella por mucho tiempo








Tuve problemas técnicos, como un mensaje de error o un error que no podía fijar








Otro, especificar AA




SPCAS0045284 AA Haznos saber por qué no se ha completado y se somete esta solicitud hoy.

Text field, no char limit
N Skip Logic OPS Why Not Complete today
SPCAS0045248
Hasta el momento, ¿cuánto tiempo ha trabajado en esta solicitud en línea? Hasta 15 minutos
Drop down select one Single Y
Time Spent



16 minutos - 30 minutos








31 minutos - 1 hora








Más de 1 hora hasta 2 horas








Más de 2 horas





SPCAS0045249
¿Fue fácil para usted para encontrar esta aplicación en línea? Muy fácil




Find App



algo fácil








algo duro A







Muy difícil A




SPCAS0045250 A Haznos saber por qué era difícil encontrar la aplicación en línea. (Seleccione todas las que apliquen.) No se pudo encontrar por dónde empezar una nueva aplicación en línea
check box one up vertical Multi Y Skip Logic Why hard to find



Donde no está claro que vaya a volver a una solicitud previamente guardada








No estaba claro para mí cuando los vínculos conducirían








Dificultad para utilizar un enlace en la página web de la Seguridad Social








La información no parecía estar organizados de una manera lógica








Usé la función de búsqueda, pero los resultados no parecen aplicarse.








Traté de usar el FAQ, pero no pude encontrar la solicitud en línea








Otro, especificar AA




SPCAS0045285 AA Por favor, explique la razón por la que era difícil para usted para encontrar la solicitud en línea.

N
N Skip Logic OPS Hard to Find
SPCAS0045286
¿Cómo llegaste a esta solicitud en línea hoy en día? Se utiliza el enlace de los servicios en línea en la página web de la Seguridad Social
Radio Button Single Y Skip Logic Arrive at App



Seguido de un enlace de algún otro lugar en el sitio web de la Seguridad Social








Se utiliza la función de búsqueda en la página web de la Seguridad Social








Se utiliza un motor de búsqueda fuera (es decir, Google, Bing, Yahoo, etc)








Seguido de un enlace desde medicare.gov








Seguido un enlace desde otro sitio web








Este sitio fue bookmarked








Otro, especificar A




SPCAS0045251 A Por favor describa cómo llegó a esta solicitud en línea hoy

Text field, no char limit
N
OPS Arrive at app
SPCAS0045252
¿Por qué eligió para aplicar en línea? (Seleccione todas las que apliquen.) Yo no quería ir a una oficina local del Seguro Social
check box one up vertical Multi Y Skip Logic Why Online



Yo no quería que la solicitud por teléfono








Yo prefiero usar los servicios en línea tanto como sea posible








Aprendí acerca de la aplicación en línea durante su visita a la página web de la Seguridad Social








Un empleado del Seguro Social recomienda que aplico en línea








Un amigo o familiar recomendaron que aplico en línea








Yo sabía que si tenía alguna pregunta o problema la aplicación en línea, todavía podía recibir ayuda de la Seguridad Social








Estoy presentando en nombre de otra persona








Otro, especificar A




SPCAS0045287 A Por favor, especifique qué decide aplicar en línea

Text field, no char limit
N
OPS Why Online
SPCAS0045289
¿Cuál es su estado civil actual? casado
Radio button, one-up vertical Single N OPS Group Marital Status


apartado








divorciado








viudo







` Nunca se ha casado








Prefiero no responder








Otro, especificar A




SPCAS0045290 A Otro estado civil

Text field, <100 char
N OPS Group OPS Marital Status
ENSTE0059662
¿Ya se registró para una cuenta de mi Seguro Social?
Radio button, one-up vertical Single Y Skip Logic Have mySSA Account



No A




SPSTE0061423 A ¿Cuál es la razón principal por la que no se haya registrado para una cuenta de mi Seguro Social? No tengo conocimiento de lo que una cuenta de mi Seguro Social es.
Radio button, one-up vertical Single Y Skip Logic Why Not Have mySSA Account



Traté de registrar una cuenta de mi Seguro Social, pero no tuvo éxito.








Actualmente estoy tratando de registrar una cuenta de mi Seguro Social.








Yo no quiero una cuenta de mi Seguro Social.








Otro (especificar): AA




SPSTE0061395 AA Por favor, díganos por qué usted no está registrado para obtener una cuenta de mi Seguridad Social.

Text field, no char limit Single N Skip Logic OPS_Why Not Have mySSA Account
SPCAS0045291
¿Tiene alguna sugerencia para mejorar la aplicación en línea de la Seguridad Social?

Text field, no char limit
N
OE_Improvement

Sheet 4: v3 CQs (EE) (7-21-14)

Model Instance Name:

red & strike-through: DELETE





SSA iClaim v3

underlined & italicized: RE-ORDER





MID: xZAAEQw81gIo1Vo4Noc1Rw4C

pink: ADDITION





Date: 7/15/2011 blue + -->: REWORDING








violet (bold): SKIP-LOGIC





SSA iClaim v3 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
BJL2231
What type of benefits were you applying for? Retirement
Dropdown (Select-one) Single Y
Type of Benefits



Medicare only








Disability








Both Retirement and Disability








Spouse's








Other





CAS0045242
Are you applying online for yourself or are you helping someone else? Myself
Dropdown (Select-one) Single Y
Applying for



Helping a Spouse/Relative/Friend








Professional Helping a Client








Other





CAS0045243
How did you learn about this online application? (Select all that apply.) Official Social Security website
check box one up vertical Multi Y Skip Logic Group Learn about App



A general web search (e.g. Google, Bing, etc.)








The radio








The television








An email from Social Security








A newspaper or magazine article








An online ad (Banner/Image)








An online video








A newspaper or magazine ad








A billboard or other printed ad








Social Media (Blog, Facebook, Twitter, etc.)








Friend, spouse, relative, neighbor or acquaintance








Social Security statement








Social Security employee A







Community Group or Association








Other, please specify B




CAS0045244 A How did you make contact with a Social Security employee? Visited a local Social Security office
check box one up vertical Multi Y Skip Logic SSA Emplyee Contact



Called a local Social Security office








Called the national 800 number








Other, please specify AA




CAS0045245 AA Please describe how you made contact with a Social Security employee.

Text box, no char limit
N Skip Logic OPS SSA Employe Contact
CAS0045246 B Please specify how you learned about this online application.

Text box, no char limit
N Skip Logic OPS Learn about App
CAS0045262
Did you use any of the following to prepare to apply online? (Select all that apply.) Reviewed my online Social Security Statement A check box one up vertical Multi Y Skip Logic Prepare for App



I used the Retirement Estimator or other tools on the Social Security website B







I watched the instructional video C







I used other information on the Social Security website to prepare D







I used another resource to prepare to apply online E







I did not use any resources to prepare to apply online





CAS0045263 A How helpful did you find the online Social Security Statement? Very helpful
Drop down select one Single Y Skip Logic Rate Statement



Somewhat helpful








Not at all helpful





CAS0045264 B How helpful did you find the estimator tools on the website? Very helpful
Drop down select one Single Y Skip Logic Rate RE Tools



Somewhat helpful








Not at all helpful





CAS0045265 C How helpful did you find the instructional video? Very helpful
Drop down select one Single Y Skip Logic Rate Video



Somewhat helpful








Not at all helpful





CAS0045266 D How helpful did you find the other information on the Social Security website? Very helpful
Drop down select one Single Y Skip Logic Rate Other Info on Website



Somewhat helpful








Not at all helpful





CAS0045267 E Please describe what other resource(s) you used to prepare to apply online?

Text field, no char limit
N Skip Logic OPS Prepare for App
CAS0045247
Did you start a new online application today or did you return to a saved application? Started a new application
Drop down select one Single Y
App Status



Returned to work on a saved application





CAS0045282
Did you complete and submit this online application today? Yes
Drop down select one Single Y Skip Logic Complete App



No, I plan to complete and submit later A







No, I do not plan to complete and submit the online application A




CAS0045283 A If you did not complete and submit this online application today, please tell us why. Too many questions
check box one up vertical Multi Y Skip Logic Not Complete App



Takes too long to fill out








Too complicated to use without help








Didn't have information I needed like names, addresses, or dates








Didn't understand what questions meant/how to answer








I wanted to use the Retirement Estimator to reconsider my retirement options








I needed to view my Social Security Statement and/or verify that my earnings record is correct








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








I had a limited amount of time/family demands that kept me from working on it for very long








I had technical problems like an error message or a mistake I couldn't fix








Other, please specify AA




CAS0045284 AA Please tell us why you did not complete and submit this application today.

Text field, no char limit
N Skip Logic OPS Why Not Complete today
CAS0045248
So far, how long have you worked on this online application? Up to 15 minutes
Drop down select one Single Y
Time Spent



16 minutes - 30 minutes








31 minutes - 1 hour








More than 1 hour up to 2 hours








More than 2 hours





CAS0045249
How easy was it for you to find this online application? Very easy




Find App



Somewhat easy








Somewhat hard A







Very hard A




CAS0045250 A Please tell us why it was hard to find the online application. (Select all that apply.) Could not find where to start a new online application
check box one up vertical Multi Y Skip Logic Why hard to find



Not clear where to go to return to a previously saved application








It was not clear to me where the links would lead








Difficulty using a link on the Social Security website








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








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








I tried to use the FAQ's, but couldn't find the online application








Other reason (please describe) AA




CAS0045285 AA Please explain the reason why it was hard for you to find the online application.

N
N Skip Logic OPS Hard to Find
CAS0045286
How did you arrive at this online application today? Used the Online Services link on the Social Security homepage
Radio Button Single Y Skip Logic Arrive at App



Followed a link from somewhere else on the Social Security website








Used the search feature on the Social Security website








Used an outside search engine (i.e. Google, Bing, yahoo etc.)








Followed a link from medicare.gov








Followed a link from another website








Site was bookmarked








Other, please specify A




CAS0045251 A Please describe how you arrived at this online application today

Text field, no char limit
N
OPS Arrive at app
CAS0045252
Why did you choose to apply online? (Select all that apply.) I did not want to go to a local Social Security office
check box one up vertical Multi Y Skip Logic Why Online



I did not want to apply over the phone








I prefer to use online services as much as possible








I learned about applying online while visiting Social Security's website








A Social Security employee recommended that I apply online








A friend or relative recommended that I apply online








I knew that if I had a question or problem applying online, I could still get help from Social Security








I am filing on behalf of another person








Other, please specify A




CAS0045287 A Please specify why you choose to apply online

Text field, no char limit
N
OPS Why Online
CAS0045289
What is your current marital status? Married
Radio button, one-up vertical Single N OPS Group Marital Status


Separated








Divorced                   







Widowed                  







Never married          








Prefer not to answer








Other, please specify A




CAS0045290 A Other marital status

Text field, <100 char
N OPS Group OPS Marital Status
STE0059662
Have you registered for a my Social Security account? Yes
Radio button, one-up vertical Single Y Skip Logic Have mySSA Account



No A




STE0061423 A What is the main reason you have not registered for a my Social Security account? I am unaware of what a my Social Security account is.
Radio button, one-up vertical Single Y Skip Logic Why Not Have mySSA Account



I tried to register for a my Social Security account, but was unsuccessful.








I am currently trying to register for a my Social Security account.








I do not want a my Social Security account.








Other (please specify): AA




STE0061395 AA Please tell us why you have not registered for a my Social Security account.

Text field, no char limit Single N Skip Logic OPS_Why Not Have mySSA Account
CAS0045291
Do you have any suggestions for improving Social Security's online application.

Text field, no char limit
N
OE_Improvement

Sheet 5: v3 CQs (EE) (7-17-14)

Model Instance Name:

red & strike-through: DELETE





SSA iClaim v3

underlined & italicized: RE-ORDER





MID: xZAAEQw81gIo1Vo4Noc1Rw4C

pink: ADDITION





Date: 7/15/2011 blue + -->: REWORDING








violet (bold): SKIP-LOGIC





SSA iClaim v3 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
BJL2231
What type of benefits were you applying for? Retirement
Dropdown (Select-one) Single Y
Type of Benefits



Medicare only








Disability








Both Retirement and Disability








Spouse's








Other





CAS0045242
Are you applying online for yourself or are you helping someone else? Myself
Dropdown (Select-one) Single Y
Applying for



Helping a Spouse/Relative/Friend








Professional Helping a Client








Other





CAS0045243
How did you learn about this online application? (Select all that apply.) Official Social Security website
check box one up vertical Multi Y Skip Logic Group Learn about App



A general web search (e.g. Google, Bing, etc.)








The radio








The television








An email from Social Security








A newspaper or magazine article








An online ad (Banner/Image)








An online video








A newspaper or magazine ad








A billboard or other printed ad








Social Media (Blog, Facebook, Twitter, etc.)








Friend, spouse, relative, neighbor or acquaintance








Social Security statement








Social Security employee A







Community Group or Association








Other, please specify B




CAS0045244 A How did you make contact with a Social Security employee? Visited a local Social Security office
check box one up vertical Multi Y Skip Logic SSA Emplyee Contact



Called a local Social Security office








Called the national 800 number








Other, please specify AA




CAS0045245 AA Please describe how you made contact with a Social Security employee.

Text box, no char limit
N Skip Logic OPS SSA Employe Contact
CAS0045246 B Please specify how you learned about this online application.

Text box, no char limit
N Skip Logic OPS Learn about App
CAS0045262
Did you use any of the following to prepare to apply online? (Select all that apply.) Reviewed my online Social Security Statement A check box one up vertical Multi Y Skip Logic Prepare for App



I used the Retirement Estimator or other tools on the Social Security website B







I watched the instructional video C







I used other information on the Social Security website to prepare D







I used another resource to prepare to apply online E







I did not use any resources to prepare to apply online





CAS0045263 A How helpful did you find the online Social Security Statement? Very helpful
Drop down select one Single Y Skip Logic Rate Statement



Somewhat helpful








Not at all helpful





CAS0045264 B How helpful did you find the estimator tools on the website? Very helpful
Drop down select one Single Y Skip Logic Rate RE Tools



Somewhat helpful








Not at all helpful





CAS0045265 C How helpful did you find the instructional video? Very helpful
Drop down select one Single Y Skip Logic Rate Video



Somewhat helpful








Not at all helpful





CAS0045266 D How helpful did you find the other information on the Social Security website? Very helpful
Drop down select one Single Y Skip Logic Rate Other Info on Website



Somewhat helpful








Not at all helpful





CAS0045267 E Please describe what other resource(s) you used to prepare to apply online?

Text field, no char limit
N Skip Logic OPS Prepare for App
CAS0045247
Did you start a new online application today or did you return to a saved application? Started a new application
Drop down select one Single Y
App Status



Returned to work on a saved application





CAS0045282
Did you complete and submit this online application today? Yes
Drop down select one Single Y Skip Logic Complete App



No, I plan to complete and submit later A







No, I do not plan to complete and submit the online application A




CAS0045283 A If you did not complete and submit this online application today, please tell us why. Too many questions
check box one up vertical Multi Y Skip Logic Not Complete App



Takes too long to fill out








Too complicated to use without help








Didn't have information I needed like names, addresses, or dates








Didn't understand what questions meant/how to answer








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








I had a limited amount of time/family demands that kept me from working on it for very long








I had technical problems like an error message or a mistake I couldn't fix








Other, please specify AA




CAS0045284 AA Please tell us why you did not complete and submit this application today.

Text field, no char limit
N Skip Logic OPS Why Not Complete today
CAS0045248
So far, how long have you worked on this online application? Up to 15 minutes
Drop down select one Single Y
Time Spent



16 minutes - 30 minutes








31 minutes - 1 hour








More than 1 hour up to 2 hours








More than 2 hours





CAS0045249
How easy was it for you to find this online application? Very easy




Find App



Somewhat easy








Somewhat hard A







Very hard A




CAS0045250 A Please tell us why it was hard to find the online application. (Select all that apply.) Could not find where to start a new online application
check box one up vertical Multi Y Skip Logic Why hard to find



Not clear where to go to return to a previously saved application








It was not clear to me where the links would lead








Difficulty using a link on the Social Security website








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








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








I tried to use the FAQ's, but couldn't find the online application








Other reason (please describe) AA




CAS0045285 AA Please explain the reason why it was hard for you to find the online application.

N
N Skip Logic OPS Hard to Find
CAS0045286
How did you arrive at this online application today? Used the Online Services link on the Social Security homepage
Radio Button Single Y Skip Logic Arrive at App



Followed a link from somewhere else on the Social Security website








Used the search feature on the Social Security website








Used an outside search engine (i.e. Google, Bing, yahoo etc.)








Followed a link from medicare.gov








Followed a link from another website








Site was bookmarked








Other, please specify A




CAS0045251 A Please describe how you arrived at this online application today

Text field, no char limit
N
OPS Arrive at app
CAS0045252
Why did you choose to apply online? (Select all that apply.) I did not want to go to a local Social Security office
check box one up vertical Multi Y Skip Logic Why Online



I did not want to apply over the phone








I prefer to use online services as much as possible








I learned about applying online while visiting Social Security's website








A Social Security employee recommended that I apply online








A friend or relative recommended that I apply online








I knew that if I had a question or problem applying online, I could still get help from Social Security








I am filing on behalf of another person








Other, please specify A




CAS0045287 A Please specify why you choose to apply online

Text field, no char limit
N
OPS Why Online
CAS0045289
What is your current marital status? Married
Radio button, one-up vertical Single N OPS Group Marital Status


Separated








Divorced                   







Widowed                  







Never married          








Prefer not to answer








Other, please specify A




CAS0045290 A Other marital status

Text field, <100 char
N OPS Group OPS Marital Status
STE0059662
Have you registered for a my Social Security account? Yes
Radio button, one-up vertical Single Y Skip Logic Have mySSA Account



No A





A What is the main reason you have not registered for a my Social Security account? I am unaware of what a my Social Security account is.
Radio button, one-up vertical Single Y Skip Logic Why Not Have mySSA Account



I tried to register for a my Social Security account, but was unsuccessful.








I am currently trying to register for a my Social Security account.








I do not want a my Social Security account.








Other (please specify): AA





AA Please tell us why you have not registered for a my Social Security account.

Text field, no char limit Single N Skip Logic OPS_Why Not Have mySSA Account
CAS0045291
Do you have any suggestions for improving Social Security's online application.

Text field, no char limit
N
OE_Improvement

Sheet 6: CQs v3 (EN) (7-17-14)

Model Instance Name:

red & strike-through: DELETE





SSA iClaim v3

underlined & italicized: RE-ORDER





MID: VgpBBYx9l8JxIFgJlY1Ikg4C

pink: ADDITION





Date: 7/15/2011 blue + -->: REWORDING








violet (bold): SKIP-LOGIC





SSA iClaim v3 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
ENBJL2231
What type of benefits were you applying for? Retirement
Dropdown (Select-one) Single Y
Type of Benefits



Medicare only








Disability








Both Retirement and Disability








Spouse's








Other





ENCAS0045242
Are you applying online for yourself or are you helping someone else? Myself
Dropdown (Select-one) Single Y
Applying for



Helping a Spouse/Relative/Friend








Professional Helping a Client








Other





ENCAS0045243
How did you learn about this online application? (Select all that apply.) Official Social Security website
check box one up vertical Multi Y Skip Logic Group Learn about App



A general web search (e.g. Google, Bing, etc.)








The radio








The television








An email from Social Security








A newspaper or magazine article








An online ad (Banner/Image)








An online video








A newspaper or magazine ad








A billboard or other printed ad








Social Media (Blog, Facebook, Twitter, etc.)








Friend, spouse, relative, neighbor or acquaintance








Social Security statement








Social Security employee A







Community Group or Association








Other, please specify B




ENCAS0045244 A How did you make contact with a Social Security employee? Visited a local Social Security office
check box one up vertical Multi Y Skip Logic SSA Emplyee Contact



Called a local Social Security office








Called the national 800 number








Other, please specify AA




ENCAS0045245 AA Please describe how you made contact with a Social Security employee.

Text box, no char limit
N Skip Logic OPS SSA Employe Contact
ENCAS0045246 B Please specify how you learned about this online application.

Text box, no char limit
N Skip Logic OPS Learn about App
ENCAS0045262
Did you use any of the following to prepare to apply online? (Select all that apply.) Reviewed my online Social Security Statement A check box one up vertical Multi Y Skip Logic Prepare for App



I used the Retirement Estimator or other tools on the Social Security website B







I watched the instructional video C







I used other information on the Social Security website to prepare D







I used another resource to prepare to apply online E







I did not use any resources to prepare to apply online





ENCAS0045263 A How helpful did you find the online Social Security Statement? Very helpful
Drop down select one Single Y Skip Logic Rate Statement



Somewhat helpful








Not at all helpful





ENCAS0045264 B How helpful did you find the estimator tools on the website? Very helpful
Drop down select one Single Y Skip Logic Rate RE Tools



Somewhat helpful








Not at all helpful





ENCAS0045265 C How helpful did you find the instructional video? Very helpful
Drop down select one Single Y Skip Logic Rate Video



Somewhat helpful








Not at all helpful





ENCAS0045266 D How helpful did you find the other information on the Social Security website? Very helpful
Drop down select one Single Y Skip Logic Rate Other Info on Website



Somewhat helpful








Not at all helpful





ENCAS0045267 E Please describe what other resource(s) you used to prepare to apply online?

Text field, no char limit
N Skip Logic OPS Prepare for App
ENCAS0045247
Did you start a new online application today or did you return to a saved application? Started a new application
Drop down select one Single Y
App Status



Returned to work on a saved application





ENCAS0045282
Did you complete and submit this online application today? Yes
Drop down select one Single Y Skip Logic Complete App



No, I plan to complete and submit later A







No, I do not plan to complete and submit the online application A




ENCAS0045283 A If you did not complete and submit this online application today, please tell us why. Too many questions
check box one up vertical Multi Y Skip Logic Not Complete App



Takes too long to fill out








Too complicated to use without help








Didn't have information I needed like names, addresses, or dates








Didn't understand what questions meant/how to answer








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








I had a limited amount of time/family demands that kept me from working on it for very long








I had technical problems like an error message or a mistake I couldn't fix








Other, please specify AA




ENCAS0045284 AA Please tell us why you did not complete and submit this application today.

Text field, no char limit
N Skip Logic OPS Why Not Complete today
ENCAS0045248
So far, how long have you worked on this online application? Up to 15 minutes
Drop down select one Single Y
Time Spent



16 minutes - 30 minutes








31 minutes - 1 hour








More than 1 hour up to 2 hours








More than 2 hours





ENCAS0045249
How easy was it for you to find this online application? Very easy




Find App



Somewhat easy








Somewhat hard A







Very hard A




ENCAS0045250 A Please tell us why it was hard to find the online application. (Select all that apply.) Could not find where to start a new online application
check box one up vertical Multi Y Skip Logic Why hard to find



Not clear where to go to return to a previously saved application








It was not clear to me where the links would lead








Difficulty using a link on the Social Security website








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








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








I tried to use the FAQ's, but couldn't find the online application








Other reason (please describe) AA




ENCAS0045285 AA Please explain the reason why it was hard for you to find the online application.

N
N Skip Logic OPS Hard to Find
ENCAS0045286
How did you arrive at this online application today? Used the Online Services link on the Social Security homepage
Radio Button Single Y Skip Logic Arrive at App



Followed a link from somewhere else on the Social Security website








Used the search feature on the Social Security website








Used an outside search engine (i.e. Google, Bing, yahoo etc.)








Followed a link from medicare.gov








Followed a link from another website








Site was bookmarked








Other, please specify A




ENCAS0045251 A Please describe how you arrived at this online application today

Text field, no char limit
N
OPS Arrive at app
ENCAS0045252
Why did you choose to apply online? (Select all that apply.) I did not want to go to a local Social Security office
check box one up vertical Multi Y Skip Logic Why Online



I did not want to apply over the phone








I prefer to use online services as much as possible








I learned about applying online while visiting Social Security's website








A Social Security employee recommended that I apply online








A friend or relative recommended that I apply online








I knew that if I had a question or problem applying online, I could still get help from Social Security








I am filing on behalf of another person








Other, please specify A




ENCAS0045287 A Please specify why you choose to apply online

Text field, no char limit
N
OPS Why Online
ENCAS0045289
What is your current marital status? Married
Radio button, one-up vertical Single N OPS Group Marital Status


Separated








Divorced                   







Widowed                  







Never married          








Prefer not to answer








Other, please specify A




ENCAS0045290 A Other marital status

Text field, <100 char
N OPS Group OPS Marital Status
ENSTE0059662
Have you registered for a my Social Security account? Yes
Radio button, one-up vertical Single Y Skip Logic Have mySSA Account



No A





A What is the main reason you have not registered for a my Social Security account? I am unaware of what a my Social Security account is.
Radio button, one-up vertical Single Y Skip Logic Why Not Have mySSA Account



I tried to register for a my Social Security account, but was unsuccessful.








I am currently trying to register for a my Social Security account.








I do not want a my Social Security account.








Other (please specify): AA





AA Please tell us why you have not registered for a my Social Security account.

Text field, no char limit Single N Skip Logic OPS_Why Not Have mySSA Account
ENCAS0045291
Do you have any suggestions for improving Social Security's online application.

Text field, no char limit
N
OE_Improvement

Sheet 7: v3 CQs (SP) (7-17-14)

Model Instance Name:

red & strike-through: DELETE





SSA iClaim v3 (Spanish)

underlined & italicized: RE-ORDER





MID: Q0ExM1xNQRl9JJUR0M0JlA4C
pink: ADDITION





Date: 7/15/2011 blue + -->: REWORDING








violet (bold): SKIP-LOGIC





SSA iClaim v3 (Spanish) 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
SPBJL2231
¿Qué tipo de beneficios estaba solicitando? Por jubilación
Dropdown (Select-one) Single Y
Type of Benefits



Solo Medicare








Por incapacidad








Tanto Jubilación y Discapacidad








Coomo cónyuge








Otro





SPCAS0045242
¿Es esta solicitud en línea para sí mismo o estás ayudando a alguien más? Yo mismo
Dropdown (Select-one) Single Y
Applying for



Cómo ayudar a un cónyuge / pariente / amigo








Profesional Ayudar a un cliente








Otro





SPCAS0045243
¿Cómo se enteró acerca de esta solicitud en línea? (Seleccione todas las que apliquen.) Sitio web oficial de la Seguridad Social
check box one up vertical Multi Y Skip Logic Group Learn about App



Una búsqueda web general (por ejemplo, Google, Bing, etc)








La radio








La televisión








Un correo electrónico de la Seguridad Social








Un periódico o la revista








Un anuncio en línea (Banner / Imagen)








Un video en línea








Un periódico o una revista de anuncios








Un anuncio impreso cartelera u otro








Medios de Comunicación Social (Blog, Facebook, Twitter, etc)








Amigo, cónyuge, pariente, vecino o conocido








Declaración del Seguro Social








Empleado del Seguro Social A







Grupo de la comunidad o de la Asociación








Otro, especificar B




SPCAS0045244 A ¿Cómo se hace el contacto con un empleado del Seguro Social? Visitado una oficina local del Seguro Social
check box one up vertical Multi Y Skip Logic SSA Emplyee Contact



Llamado a la oficina local del Seguro Social








Llamado el número nacional 800








Otro, especificar AA




SPCAS0045245 AA Por favor describa cómo se hizo contacto con un empleado del Seguro Social.

Text box, no char limit
N Skip Logic OPS SSA Employe Contact
SPCAS0045246 B Por favor, especifique cómo se enteró de esta aplicación en línea.

Text box, no char limit
N Skip Logic OPS Learn about App
SPCAS0045262
¿Ha usado alguna de las siguientes acciones para prepararse para aplicar en línea? (Seleccione todas las que apliquen.) Comentado mi Declaración del Seguro Social en línea A check box one up vertical Multi Y Skip Logic Prepare for App



He utilizado el Retirement Estimator u otras herramientas en el sitio web de la Seguridad Social B







Vi el video de instrucciones C







Usé otra información en la página web de la Seguridad Social para preparar D







Utilicé otro recurso que se preparen para aplicar en línea E







No hice uso de los recursos para prepararse para aplicar en línea





SPCAS0045263 A ¿Qué tan útil ha encontrado el Declaración del Seguro Social en línea? Muy útil
Drop down select one Single Y Skip Logic Rate Statement



algo útil








Para nada útil





SPCAS0045264 B ¿Qué tan útil encontraste las herramientas estimador en el sitio web? Muy útil
Drop down select one Single Y Skip Logic Rate RE Tools



algo útil








Para nada útil





SPCAS0045265 C ¿Qué tan útil le parecen la video instructivo? Muy útil
Drop down select one Single Y Skip Logic Rate Video



algo útil








Para nada útil





SPCAS0045266 D ¿Qué tan útil le parecen la otra información en el sitio web de la Seguridad Social? Muy útil
Drop down select one Single Y Skip Logic Rate Other Info on Website



algo útil








Para nada útil





SPCAS0045267 E Por favor describa lo otro recurso (s) que utilizó para prepararse para aplicar en línea.

Text field, no char limit
N Skip Logic OPS Prepare for App
SPCAS0045247
¿Comenzó una nueva aplicación en línea hoy mismo o que te vuelva a una solicitud guardada? Comenzó una nueva aplicación
Drop down select one Single Y
App Status



Volvió a trabajar en una solicitud guardada





SPCAS0045282
¿Sabía usted completar y presentar esta solicitud en línea hoy en día?
Drop down select one Single Y Skip Logic Complete App



No, tengo la intención de completar y enviar más tarde A







No, no tengo planes para completar y enviar la solicitud en línea A




SPCAS0045283 A Si no logró completar y presentar esta solicitud en línea hoy, por favor díganos por qué. Demasiadas preguntas
check box one up vertical Multi Y Skip Logic Not Complete App



Toma demasiado tiempo para llenar








Demasiado complicado de usar sin ayuda








No tenía la información que necesitaba como nombres, direcciones o fechas








No entendía lo que significaba preguntas / cómo responder








Mi condición de discapacidad me impide trabajar con una computadora por largos periodos








Yo tenía una cantidad limitada de demandas de tiempo / de la familia que me impedía trabajar en ella por mucho tiempo








Tuve problemas técnicos, como un mensaje de error o un error que no podía fijar








Otro, especificar AA




SPCAS0045284 AA Haznos saber por qué no se ha completado y se somete esta solicitud hoy.

Text field, no char limit
N Skip Logic OPS Why Not Complete today
SPCAS0045248
Hasta el momento, ¿cuánto tiempo ha trabajado en esta solicitud en línea? Hasta 15 minutos
Drop down select one Single Y
Time Spent



16 minutos - 30 minutos








31 minutos - 1 hora








Más de 1 hora hasta 2 horas








Más de 2 horas





SPCAS0045249
¿Fue fácil para usted para encontrar esta aplicación en línea? Muy fácil




Find App



algo fácil








algo duro A







Muy difícil A




SPCAS0045250 A Haznos saber por qué era difícil encontrar la aplicación en línea. (Seleccione todas las que apliquen.) No se pudo encontrar por dónde empezar una nueva aplicación en línea
check box one up vertical Multi Y Skip Logic Why hard to find



Donde no está claro que vaya a volver a una solicitud previamente guardada








No estaba claro para mí cuando los vínculos conducirían








Dificultad para utilizar un enlace en la página web de la Seguridad Social








La información no parecía estar organizados de una manera lógica








Usé la función de búsqueda, pero los resultados no parecen aplicarse.








Traté de usar el FAQ, pero no pude encontrar la solicitud en línea








Otro, especificar AA




SPCAS0045285 AA Por favor, explique la razón por la que era difícil para usted para encontrar la solicitud en línea.

N
N Skip Logic OPS Hard to Find
SPCAS0045286
¿Cómo llegaste a esta solicitud en línea hoy en día? Se utiliza el enlace de los servicios en línea en la página web de la Seguridad Social
Radio Button Single Y Skip Logic Arrive at App



Seguido de un enlace de algún otro lugar en el sitio web de la Seguridad Social








Se utiliza la función de búsqueda en la página web de la Seguridad Social








Se utiliza un motor de búsqueda fuera (es decir, Google, Bing, Yahoo, etc)








Seguido de un enlace desde medicare.gov








Seguido un enlace desde otro sitio web








Este sitio fue bookmarked








Otro, especificar A




SPCAS0045251 A Por favor describa cómo llegó a esta solicitud en línea hoy

Text field, no char limit
N
OPS Arrive at app
SPCAS0045252
¿Por qué eligió para aplicar en línea? (Seleccione todas las que apliquen.) Yo no quería ir a una oficina local del Seguro Social
check box one up vertical Multi Y Skip Logic Why Online



Yo no quería que la solicitud por teléfono








Yo prefiero usar los servicios en línea tanto como sea posible








Aprendí acerca de la aplicación en línea durante su visita a la página web de la Seguridad Social








Un empleado del Seguro Social recomienda que aplico en línea








Un amigo o familiar recomendaron que aplico en línea








Yo sabía que si tenía alguna pregunta o problema la aplicación en línea, todavía podía recibir ayuda de la Seguridad Social








Estoy presentando en nombre de otra persona








Otro, especificar A




SPCAS0045287 A Por favor, especifique qué decide aplicar en línea

Text field, no char limit
N
OPS Why Online
SPCAS0045289
¿Cuál es su estado civil actual? casado
Radio button, one-up vertical Single N OPS Group Marital Status


apartado








divorciado








viudo







` Nunca se ha casado








Prefiero no responder








Otro, especificar A




SPCAS0045290 A Otro estado civil

Text field, <100 char
N OPS Group OPS Marital Status
ENSTE0059662
¿Ya se registró para una cuenta de mi Seguro Social?
Radio button, one-up vertical Single Y Skip Logic Have mySSA Account



No A





A ¿Cuál es la razón principal por la que no se haya registrado para una cuenta de mi Seguro Social? No tengo conocimiento de lo que una cuenta de mi Seguro Social es.
Radio button, one-up vertical Single Y Skip Logic Why Not Have mySSA Account



Traté de registrar una cuenta de mi Seguro Social, pero no tuvo éxito.








Actualmente estoy tratando de registrar una cuenta de mi Seguro Social.








Yo no quiero una cuenta de mi Seguro Social.








Otro (especificar): AA





AA Por favor, díganos por qué usted no está registrado para obtener una cuenta de mi Seguridad Social.

Text field, no char limit Single N Skip Logic OPS_Why Not Have mySSA Account
SPCAS0045291
¿Tiene alguna sugerencia para mejorar la aplicación en línea de la Seguridad Social?

Text field, no char limit
N
OE_Improvement

Sheet 8: v3 CQs (EE) (6-12-14)

Model Instance Name:

red & strike-through: DELETE





SSA iClaim v3

underlined & italicized: RE-ORDER





MID: xZAAEQw81gIo1Vo4Noc1Rw4C

pink: ADDITION





Date: 7/15/2011 blue + -->: REWORDING








violet (bold): SKIP-LOGIC





SSA iClaim v3 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
BJL2231
What type of benefits were you applying for? Retirement
Dropdown (Select-one) Single Y Skip Logic Group Type of Benefits



Medicare only








Disability








Both Retirement and Disability








Spouse's








Other





CAS0045242
Are you applying online for yourself or are you helping someone else? Myself
Dropdown (Select-one) Single Y
Applying for



Helping a Spouse/Relative/Friend








Professional Helping a Client








Other





CAS0045243
How did you learn about this online application? (Select all that apply.) Official Social Security website
check box one up vertical Multi Y Skip Logic Group Learn about App



A general web search (e.g. Google, Bing, etc.)








The radio








The television








An email from Social Security








A newspaper or magazine article








An online ad (Banner/Image)








An online video








A newspaper or magazine ad








A billboard or other printed ad








Social Media (Blog, Facebook, Twitter, etc.)








Friend, spouse, relative, neighbor or acquaintance








Social Security statement








Social Security employee A







Community Group or Association








Other, please specify B




CAS0045244 A How did you make contact with a Social Security employee? Visited a local Social Security office
check box one up vertical Multi Y Skip Logic SSA Emplyee Contact



Called a local Social Security office








Called the national 800 number








Other, please specify AA




CAS0045245 AA Please describe how you made contact with a Social Security employee.

Text box, no char limit
N Skip Logic OPS SSA Employe Contact
CAS0045246 B Please specify how you learned about this online application.

Text box, no char limit
N Skip Logic OPS Learn about App
CAS0045262
Did you use any of the following to prepare to apply online? (Select all that apply.) Reviewed my online Social Security Statement A check box one up vertical Multi Y Skip Logic Prepare for App



I used the Retirement Estimator or other tools on the Social Security website B







I watched the instructional video C







I used other information on the Social Security website to prepare D







I used another resource to prepare to apply online E







I did not use any resources to prepare to apply online





CAS0045263 A How helpful did you find the online Social Security Statement? Very helpful
Drop down select one Single Y Skip Logic Rate Statement



Somewhat helpful








Not at all helpful





CAS0045264 B How helpful did you find the estimator tools on the website? Very helpful
Drop down select one Single Y Skip Logic Rate RE Tools



Somewhat helpful








Not at all helpful





CAS0045265 C How helpful did you find the instructional video? Very helpful
Drop down select one Single Y Skip Logic Rate Video



Somewhat helpful








Not at all helpful





CAS0045266 D How helpful did you find the other information on the Social Security website? Very helpful
Drop down select one Single Y Skip Logic Rate Other Info on Website



Somewhat helpful








Not at all helpful





CAS0045267 E Please describe what other resource(s) you used to prepare to apply online?

Text field, no char limit
N Skip Logic OPS Prepare for App
CAS0045247
Did you start a new online application today or did you return to a saved application? Started a new application
Drop down select one Single Y
App Status



Returned to work on a saved application





CAS0045282
Did you complete and submit this online application today? Yes
Drop down select one Single Y Skip Logic Complete App



No, I plan to complete and submit later A







No, I do not plan to complete and submit the online application A




CAS0045283 A If you did not complete and submit this online application today, please tell us why. Too many questions
check box one up vertical Multi Y Skip Logic Not Complete App



Takes too long to fill out








Too complicated to use without help








Didn't have information I needed like names, addresses, or dates








Didn't understand what questions meant/how to answer








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








I had a limited amount of time/family demands that kept me from working on it for very long








I had technical problems like an error message or a mistake I couldn't fix








Other, please specify AA




CAS0045284 AA Please tell us why you did not complete and submit this application today.

Text field, no char limit
N Skip Logic OPS Why Not Complete today
CAS0045248
So far, how long have you worked on this online application? Up to 15 minutes
Drop down select one Single Y
Time Spent



16 minutes - 30 minutes








31 minutes - 1 hour








More than 1 hour up to 2 hours








More than 2 hours





CAS0045249
How easy was it for you to find this online application? Very easy




Find App



Somewhat easy








Somewhat hard A







Very hard A




CAS0045250 A Please tell us why it was hard to find the online application. (Select all that apply.) Could not find where to start a new online application
check box one up vertical Multi Y Skip Logic Why hard to find



Not clear where to go to return to a previously saved application








It was not clear to me where the links would lead








Difficulty using a link on the Social Security website








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








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








I tried to use the FAQ's, but couldn't find the online application








Other reason (please describe) AA




CAS0045285 AA Please explain the reason why it was hard for you to find the online application.

N
N Skip Logic OPS Hard to Find
CAS0045286
How did you arrive at this online application today? Used the Online Services link on the Social Security homepage
Radio Button Single Y Skip Logic Arrive at App



Followed a link from somewhere else on the Social Security website








Used the search feature on the Social Security website








Used an outside search engine (i.e. Google, Bing, yahoo etc.)








Followed a link from medicare.gov








Followed a link from another website








Site was bookmarked








Other, please specify A




CAS0045251 A Please describe how you arrived at this online application today

Text field, no char limit
N
OPS Arrive at app
CAS0045252
Why did you choose to apply online? (Select all that apply.) I did not want to go to a local Social Security office
check box one up vertical Multi Y Skip Logic Why Online



I did not want to apply over the phone








I prefer to use online services as much as possible








I learned about applying online while visiting Social Security's website








A Social Security employee recommended that I apply online








A friend or relative recommended that I apply online








I knew that if I had a question or problem applying online, I could still get help from Social Security








I am filing on behalf of another person








Other, please specify A




CAS0045287 A Please specify why you choose to apply online

Text field, no char limit
N
OPS Why Online
CAS0045289
What is your current marital status? Married
Radio button, one-up vertical Single N OPS Group Marital Status


Separated








Divorced                   







Widowed                  







Never married          








Prefer not to answer








Other, please specify A




CAS0045290 A Other marital status

Text field, <100 char
N OPS Group OPS Marital Status


Do you presently have an active my Social Security account established? Yes
Radio button, one-up vertical Single Y
Have mySSA Account



No





CAS0045291
Do you have any suggestions for improving Social Security's online application.

Text field, no char limit
N
OE_Improvement

Sheet 9: CQs v3 (EN) (6-12-14)

Model Instance Name:

red & strike-through: DELETE





SSA iClaim v3

underlined & italicized: RE-ORDER





MID: VgpBBYx9l8JxIFgJlY1Ikg4C

pink: ADDITION





Date: 7/15/2011 blue + -->: REWORDING








violet (bold): SKIP-LOGIC





SSA iClaim v3 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
ENBJL2231
What type of benefits were you applying for? Retirement
Dropdown (Select-one) Single Y skip logic group Type of Benefits



Medicare only








Disability








Both Retirement and Disability








Spouse's








Other





ENCAS0045242
Are you applying online for yourself or are you helping someone else? Myself
Dropdown (Select-one) Single Y
Applying for



Helping a Spouse/Relative/Friend








Professional Helping a Client








Other





ENCAS0045243
How did you learn about this online application? (Select all that apply.) Official Social Security website
check box one up vertical Multi Y Skip Logic Group Learn about App



A general web search (e.g. Google, Bing, etc.)








The radio








The television








An email from Social Security








A newspaper or magazine article








An online ad (Banner/Image)








An online video








A newspaper or magazine ad








A billboard or other printed ad








Social Media (Blog, Facebook, Twitter, etc.)








Friend, spouse, relative, neighbor or acquaintance








Social Security statement








Social Security employee A







Community Group or Association








Other, please specify B




ENCAS0045244 A How did you make contact with a Social Security employee? Visited a local Social Security office
check box one up vertical Multi Y Skip Logic SSA Emplyee Contact



Called a local Social Security office








Called the national 800 number








Other, please specify AA




ENCAS0045245 AA Please describe how you made contact with a Social Security employee.

Text box, no char limit
N Skip Logic OPS SSA Employe Contact
ENCAS0045246 B Please specify how you learned about this online application.

Text box, no char limit
N Skip Logic OPS Learn about App
ENCAS0045262
Did you use any of the following to prepare to apply online? (Select all that apply.) Reviewed my online Social Security Statement A check box one up vertical Multi Y Skip Logic Prepare for App



I used the Retirement Estimator or other tools on the Social Security website B







I watched the instructional video C







I used other information on the Social Security website to prepare D







I used another resource to prepare to apply online E







I did not use any resources to prepare to apply online





ENCAS0045263 A How helpful did you find the online Social Security Statement? Very helpful
Drop down select one Single Y Skip Logic Rate Statement



Somewhat helpful








Not at all helpful





ENCAS0045264 B How helpful did you find the estimator tools on the website? Very helpful
Drop down select one Single Y Skip Logic Rate RE Tools



Somewhat helpful








Not at all helpful





ENCAS0045265 C How helpful did you find the instructional video? Very helpful
Drop down select one Single Y Skip Logic Rate Video



Somewhat helpful








Not at all helpful





ENCAS0045266 D How helpful did you find the other information on the Social Security website? Very helpful
Drop down select one Single Y Skip Logic Rate Other Info on Website



Somewhat helpful








Not at all helpful





ENCAS0045267 E Please describe what other resource(s) you used to prepare to apply online?

Text field, no char limit
N Skip Logic OPS Prepare for App
ENCAS0045247
Did you start a new online application today or did you return to a saved application? Started a new application
Drop down select one Single Y
App Status



Returned to work on a saved application





ENCAS0045282
Did you complete and submit this online application today? Yes
Drop down select one Single Y Skip Logic Complete App



No, I plan to complete and submit later A







No, I do not plan to complete and submit the online application A




ENCAS0045283 A If you did not complete and submit this online application today, please tell us why. Too many questions
check box one up vertical Multi Y Skip Logic Not Complete App



Takes too long to fill out








Too complicated to use without help








Didn't have information I needed like names, addresses, or dates








Didn't understand what questions meant/how to answer








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








I had a limited amount of time/family demands that kept me from working on it for very long








I had technical problems like an error message or a mistake I couldn't fix








Other, please specify AA




ENCAS0045284 AA Please tell us why you did not complete and submit this application today.

Text field, no char limit
N Skip Logic OPS Why Not Complete today
ENCAS0045248
So far, how long have you worked on this online application? Up to 15 minutes
Drop down select one Single Y
Time Spent



16 minutes - 30 minutes








31 minutes - 1 hour








More than 1 hour up to 2 hours








More than 2 hours





ENCAS0045249
How easy was it for you to find this online application? Very easy




Find App



Somewhat easy








Somewhat hard A







Very hard A




ENCAS0045250 A Please tell us why it was hard to find the online application. (Select all that apply.) Could not find where to start a new online application
check box one up vertical Multi Y Skip Logic Why hard to find



Not clear where to go to return to a previously saved application








It was not clear to me where the links would lead








Difficulty using a link on the Social Security website








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








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








I tried to use the FAQ's, but couldn't find the online application








Other reason (please describe) AA




ENCAS0045285 AA Please explain the reason why it was hard for you to find the online application.

N
N Skip Logic OPS Hard to Find
ENCAS0045286
How did you arrive at this online application today? Used the Online Services link on the Social Security homepage
Radio Button Single Y Skip Logic Arrive at App



Followed a link from somewhere else on the Social Security website








Used the search feature on the Social Security website








Used an outside search engine (i.e. Google, Bing, yahoo etc.)








Followed a link from medicare.gov








Followed a link from another website








Site was bookmarked








Other, please specify A




ENCAS0045251 A Please describe how you arrived at this online application today

Text field, no char limit
N
OPS Arrive at app
ENCAS0045252
Why did you choose to apply online? (Select all that apply.) I did not want to go to a local Social Security office
check box one up vertical Multi Y Skip Logic Why Online



I did not want to apply over the phone








I prefer to use online services as much as possible








I learned about applying online while visiting Social Security's website








A Social Security employee recommended that I apply online








A friend or relative recommended that I apply online








I knew that if I had a question or problem applying online, I could still get help from Social Security








I am filing on behalf of another person








Other, please specify A




ENCAS0045287 A Please specify why you choose to apply online

Text field, no char limit
N
OPS Why Online
ENCAS0045289
What is your current marital status? Married
Radio button, one-up vertical Single N OPS Group Marital Status


Separated








Divorced                   







Widowed                  







Never married          








Prefer not to answer








Other, please specify A




ENCAS0045290 A Other marital status

Text field, <100 char
N OPS Group OPS Marital Status


Do you presently have an active my Social Security account established? Yes
Radio button, one-up vertical Single Y
Have mySSA Account



No





ENCAS0045291
Do you have any suggestions for improving Social Security's online application.

Text field, no char limit
N
OE_Improvement

Sheet 10: v3 CQs (SP) (6-12-14)

Model Instance Name:

red & strike-through: DELETE





SSA iClaim v3 (Spanish)

underlined & italicized: RE-ORDER





MID: Q0ExM1xNQRl9JJUR0M0JlA4C
pink: ADDITION





Date: 7/15/2011 blue + -->: REWORDING








violet (bold): SKIP-LOGIC





SSA iClaim v3 (Spanish) 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
SPBJL2231
¿Qué tipo de beneficios estaba solicitando? Por jubilación
Dropdown (Select-one) Single Y Skip Logic Group Type of Benefits



Solo Medicare








Por incapacidad








Tanto Jubilación y Discapacidad








Coomo cónyuge








Otro





SPCAS0045242
¿Es esta solicitud en línea para sí mismo o estás ayudando a alguien más? Yo mismo
Dropdown (Select-one) Single Y
Applying for



Cómo ayudar a un cónyuge / pariente / amigo








Profesional Ayudar a un cliente








Otro





SPCAS0045243
¿Cómo se enteró acerca de esta solicitud en línea? (Seleccione todas las que apliquen.) Sitio web oficial de la Seguridad Social
check box one up vertical Multi Y Skip Logic Group Learn about App



Una búsqueda web general (por ejemplo, Google, Bing, etc)








La radio








La televisión








Un correo electrónico de la Seguridad Social








Un periódico o la revista








Un anuncio en línea (Banner / Imagen)








Un video en línea








Un periódico o una revista de anuncios








Un anuncio impreso cartelera u otro








Medios de Comunicación Social (Blog, Facebook, Twitter, etc)








Amigo, cónyuge, pariente, vecino o conocido








Declaración del Seguro Social








Empleado del Seguro Social A







Grupo de la comunidad o de la Asociación








Otro, especificar B




SPCAS0045244 A ¿Cómo se hace el contacto con un empleado del Seguro Social? Visitado una oficina local del Seguro Social
check box one up vertical Multi Y Skip Logic SSA Emplyee Contact



Llamado a la oficina local del Seguro Social








Llamado el número nacional 800








Otro, especificar AA




SPCAS0045245 AA Por favor describa cómo se hizo contacto con un empleado del Seguro Social.

Text box, no char limit
N Skip Logic OPS SSA Employe Contact
SPCAS0045246 B Por favor, especifique cómo se enteró de esta aplicación en línea.

Text box, no char limit
N Skip Logic OPS Learn about App
SPCAS0045262
¿Ha usado alguna de las siguientes acciones para prepararse para aplicar en línea? (Seleccione todas las que apliquen.) Comentado mi Declaración del Seguro Social en línea A check box one up vertical Multi Y Skip Logic Prepare for App



He utilizado el Retirement Estimator u otras herramientas en el sitio web de la Seguridad Social B







Vi el video de instrucciones C







Usé otra información en la página web de la Seguridad Social para preparar D







Utilicé otro recurso que se preparen para aplicar en línea E







No hice uso de los recursos para prepararse para aplicar en línea





SPCAS0045263 A ¿Qué tan útil ha encontrado el Declaración del Seguro Social en línea? Muy útil
Drop down select one Single Y Skip Logic Rate Statement



algo útil








Para nada útil





SPCAS0045264 B ¿Qué tan útil encontraste las herramientas estimador en el sitio web? Muy útil
Drop down select one Single Y Skip Logic Rate RE Tools



algo útil








Para nada útil





SPCAS0045265 C ¿Qué tan útil le parecen la video instructivo? Muy útil
Drop down select one Single Y Skip Logic Rate Video



algo útil








Para nada útil





SPCAS0045266 D ¿Qué tan útil le parecen la otra información en el sitio web de la Seguridad Social? Muy útil
Drop down select one Single Y Skip Logic Rate Other Info on Website



algo útil








Para nada útil





SPCAS0045267 E Por favor describa lo otro recurso (s) que utilizó para prepararse para aplicar en línea.

Text field, no char limit
N Skip Logic OPS Prepare for App
SPCAS0045247
¿Comenzó una nueva aplicación en línea hoy mismo o que te vuelva a una solicitud guardada? Comenzó una nueva aplicación
Drop down select one Single Y
App Status



Volvió a trabajar en una solicitud guardada





SPCAS0045282
¿Sabía usted completar y presentar esta solicitud en línea hoy en día?
Drop down select one Single Y Skip Logic Complete App



No, tengo la intención de completar y enviar más tarde A







No, no tengo planes para completar y enviar la solicitud en línea A




SPCAS0045283 A Si no logró completar y presentar esta solicitud en línea hoy, por favor díganos por qué. Demasiadas preguntas
check box one up vertical Multi Y Skip Logic Not Complete App



Toma demasiado tiempo para llenar








Demasiado complicado de usar sin ayuda








No tenía la información que necesitaba como nombres, direcciones o fechas








No entendía lo que significaba preguntas / cómo responder








Mi condición de discapacidad me impide trabajar con una computadora por largos periodos








Yo tenía una cantidad limitada de demandas de tiempo / de la familia que me impedía trabajar en ella por mucho tiempo








Tuve problemas técnicos, como un mensaje de error o un error que no podía fijar








Otro, especificar AA




SPCAS0045284 AA Haznos saber por qué no se ha completado y se somete esta solicitud hoy.

Text field, no char limit
N Skip Logic OPS Why Not Complete today
SPCAS0045248
Hasta el momento, ¿cuánto tiempo ha trabajado en esta solicitud en línea? Hasta 15 minutos
Drop down select one Single Y
Time Spent



16 minutos - 30 minutos








31 minutos - 1 hora








Más de 1 hora hasta 2 horas








Más de 2 horas





SPCAS0045249
¿Fue fácil para usted para encontrar esta aplicación en línea? Muy fácil




Find App



algo fácil








algo duro A







Muy difícil A




SPCAS0045250 A Haznos saber por qué era difícil encontrar la aplicación en línea. (Seleccione todas las que apliquen.) No se pudo encontrar por dónde empezar una nueva aplicación en línea
check box one up vertical Multi Y Skip Logic Why hard to find



Donde no está claro que vaya a volver a una solicitud previamente guardada








No estaba claro para mí cuando los vínculos conducirían








Dificultad para utilizar un enlace en la página web de la Seguridad Social








La información no parecía estar organizados de una manera lógica








Usé la función de búsqueda, pero los resultados no parecen aplicarse.








Traté de usar el FAQ, pero no pude encontrar la solicitud en línea








Otro, especificar AA




SPCAS0045285 AA Por favor, explique la razón por la que era difícil para usted para encontrar la solicitud en línea.

N
N Skip Logic OPS Hard to Find
SPCAS0045286
¿Cómo llegaste a esta solicitud en línea hoy en día? Se utiliza el enlace de los servicios en línea en la página web de la Seguridad Social
Radio Button Single Y Skip Logic Arrive at App



Seguido de un enlace de algún otro lugar en el sitio web de la Seguridad Social








Se utiliza la función de búsqueda en la página web de la Seguridad Social








Se utiliza un motor de búsqueda fuera (es decir, Google, Bing, Yahoo, etc)








Seguido de un enlace desde medicare.gov








Seguido un enlace desde otro sitio web








Este sitio fue bookmarked








Otro, especificar A




SPCAS0045251 A Por favor describa cómo llegó a esta solicitud en línea hoy

Text field, no char limit
N
OPS Arrive at app
SPCAS0045252
¿Por qué eligió para aplicar en línea? (Seleccione todas las que apliquen.) Yo no quería ir a una oficina local del Seguro Social
check box one up vertical Multi Y Skip Logic Why Online



Yo no quería que la solicitud por teléfono








Yo prefiero usar los servicios en línea tanto como sea posible








Aprendí acerca de la aplicación en línea durante su visita a la página web de la Seguridad Social








Un empleado del Seguro Social recomienda que aplico en línea








Un amigo o familiar recomendaron que aplico en línea








Yo sabía que si tenía alguna pregunta o problema la aplicación en línea, todavía podía recibir ayuda de la Seguridad Social








Estoy presentando en nombre de otra persona








Otro, especificar A




SPCAS0045287 A Por favor, especifique qué decide aplicar en línea

Text field, no char limit
N
OPS Why Online
SPCAS0045289
¿Cuál es su estado civil actual? casado
Radio button, one-up vertical Single N OPS Group Marital Status


apartado








divorciado








viudo







` Nunca se ha casado








Prefiero no responder








Otro, especificar A




SPCAS0045290 A Otro estado civil

Text field, <100 char
N OPS Group OPS Marital Status


¿Tiene actualmente una cuenta activa de my Social Security establecido?
Radio button, one-up vertical Single Y
Have mySSA Account



No





SPCAS0045291
¿Tiene alguna sugerencia para mejorar la aplicación en línea de la Seguridad Social?

Text field, no char limit
N
OE_Improvement

Sheet 11: v3 CQs (EE) (12-10-13)

Model Instance Name:

red & strike-through: DELETE










SSA iClaim v3

underlined & italicized: RE-ORDER










MID: xZAAEQw81gIo1Vo4Noc1Rw4C

pink: ADDITION










Date: 7/15/2011 blue + -->: REWORDING













violet (bold): SKIP-LOGIC










SSA iClaim v3 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




BJL2230
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










BJL2231
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







Medicare only













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












Both Retirement and Disability













Spouse's M, Q, R, X, Y, Z, U, E, W












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












I am not applying today












Are you applying online for yourself or are you helping someone else? Myself
Dropdown (Select-one) Single Y
Applying for







Helping a Spouse/Relative/Friend













Professional Helping a Client













Other












How did you learn about this online application? (Select all that apply.) Official Social Security website
check box one up vertical Multi Y Skip Logic Group Learn about App







A general web search (e.g. Google, Bing, etc.)













The radio













The television













An email from Social Security













A newspaper or magazine article













An online ad (Banner/Image)













An online video













A newspaper or magazine ad













A billboard or other printed ad













Social Media (Blog, Facebook, Twitter, etc.)













Friend, spouse, relative, neighbor or acquaintance













Social Security statement













Social Security employee A












Community Group or Association













Other, please specify B










A How did you make contact with a Social Security employee? Visited a local Social Security office
check box one up vertical Multi Y Skip Logic SSA Emplyee Contact







Called a local Social Security office













Called the national 800 number













Other, please specify AA










AA Please describe how you made contact with a Social Security employee.

Text box, no char limit
N Skip Logic OPS SSA Employe Contact





B Please specify how you learned about this online application.

Text box, no char limit
N Skip Logic OPS Learn about App






Did you use any of the following to prepare to apply online? (Select all that apply.) Reviewed my online Social Security Statement A check box one up vertical Multi Y Skip Logic Prepare for App







I used the Retirement Estimator or other tools on the Social Security website B












I watched the instructional video C












I used other information on the Social Security website to prepare D












I used another resource to prepare to apply online E












I did not use any resources to prepare to apply online











A How helpful did you find the online Social Security Statement? Very helpful
Drop down select one Single Y Skip Logic Rate Statement







Somewhat helpful













Not at all helpful











B How helpful did you find the estimator tools on the website? Very helpful
Drop down select one Single Y Skip Logic Rate RE Tools







Somewhat helpful













Not at all helpful











C How helpful did you find the instructional video? Very helpful
Drop down select one Single Y Skip Logic Rate Video







Somewhat helpful













Not at all helpful











D How helpful did you find the other information on the Social Security website? Very helpful
Drop down select one Single Y Skip Logic Rate Other Info on Website







Somewhat helpful













Not at all helpful











E Please describe what other resource(s) you used to prepare to apply online?

Text field, no char limit
N Skip Logic OPS Prepare for App






Did you start a new online application today or did you return to a saved application? Started a new application
Drop down select one Single Y
App Status







Returned to work on a saved application












Did you complete and submit this online application today? Yes
Drop down select one Single Y Skip Logic Complete App







No, I plan to complete and submit later A












No, I do not plan to complete and submit the online application A










A If you did not complete and submit this online application today, please tell us why. Too many questions
check box one up vertical Multi Y Skip Logic Not Complete App







Takes too long to fill out













Too complicated to use without help













Didn't have information I needed like names, addresses, or dates













Didn't understand what questions meant/how to answer













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













I had a limited amount of time/family demands that kept me from working on it for very long













I had technical problems like an error message or a mistake I couldn't fix













Other, please specify AA










AA Please tell us why you did not complete and submit this application today.

Text field, no char limit
N Skip Logic OPS Why Not Complete today






So far, how long have you worked on this online application? Up to 15 minutes
Drop down select one Single Y
Time Spent







16 minutes - 30 minutes













31 minutes - 1 hour













More than 1 hour up to 2 hours













More than 2 hours












How easy was it for you to find this online application? Very easy




Find App







Somewhat easy













Somewhat hard A












Very hard A










A Please tell us why it was hard to find the online application. (Select all that apply.) Could not find where to start a new online application
check box one up vertical Multi Y Skip Logic Why hard to find







Not clear where to go to return to a previously saved application













It was not clear to me where the links would lead













Difficulty using a link on the Social Security website













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













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













I tried to use the FAQ's, but couldn't find the online application













Other reason (please describe) AA










AA Please explain the reason why it was hard for you to find the online application.

N
N Skip Logic OPS Hard to Find






How did you arrive at this online application today? Used the Online Services link on the Social Security homepage
Radio Button Single Y Skip Logic Arrive at App







Followed a link from somewhere else on the Social Security website













Used the search feature on the Social Security website













Used an outside search engine (i.e. Google, Bing, yahoo etc.)













Followed a link from medicare.gov













Followed a link from another website













Site was bookmarked













Other, please specify A










A Please describe how you arrived at this online application today

Text field, no char limit
N
OPS Arrive at app






Why did you choose to apply online? (Select all that apply.) I did not want to go to a local Social Security office
check box one up vertical Multi Y Skip Logic Why Online







I did not want to apply over the phone













I prefer to use online services as much as possible













I learned about applying online while visiting Social Security's website













A Social Security employee recommended that I apply online













A friend or relative recommended that I apply online













I knew that if I had a question or problem applying online, I could still get help from Social Security













I am filing on behalf of another person













Other, please specify A










A Please specify why you choose to apply online

Text field, no char limit
N
OPS Why Online






What is your current marital status? Married
Radio button, one-up vertical Single N OPS Group Marital Status






Separated













Divorced                   












Widowed                  












Never married          













Prefer not to answer













Other, please specify A










A Other marital status

Text field, <100 char
N OPS Group OPS Marital Status






Do you have any suggestions for improving Social Security's online application.

Text field, no char limit
N
OE_Improvement




BJL2232 M How did you learn about the Social Security online application? (Select all that apply.) Official Social Security website
Checkbox One Up Vertical Multi Y Skip Logic Group Learn About Online App



Types



A general web search (e.g. Google, Bing, etc.)













The radio













The television













An email from Social Security













A newspaper or magazine article













An online ad (Banner/Image)













An online video













A newspaper or magazine ad













A billboard or other printed ad













Social Media (Blog, Facebook, Twitter, etc.)













Friend, spouse, relative, neighbor or acquaintance













Social Security statement













Social Security employee B












Community Group or Association













Other, please specify A









BJL2233 A Please specify how you learned of Social Security online.

Text area, no char limit
N Skip Logic Group OE_Learn about online app




BJL2234 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









BJL2235 D Please describe the way you made contact with a social security employee.

Text field, <100 char
N Skip Logic Group OE_Contact SSA Employee




BJL2236 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










BJL2237 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










BJL2238 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









BJL2239 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




BJL2240 X Did you visit the Social Security home page (www.socialsecurity.gov) today? Yes
Dropdown (Select-one) Single Y Skip Logic Group Homepage







No










BJL2241 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










BJL2242 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









BJL2243 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









BJL2244 Z2 Please explain the reason you found it somewhat difficult to find the application.

Text area, no char limit
N Skip Logic Group OE_Difficult to Find




BJL2245 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










BJL2246 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










BJL2247 F What part of the instructions was not clear?

Text area, no char limit
N Skip Logic Group OE_Clarity of Instructions




BJL2248 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










BJL2249 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




BJL2250
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









BJL2251 B Please specify what influenced your decision to file for benefits online.

Text area, no char limit
N Skip Logic Group OE_Influenced Decision




BJL2252 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









BJL2253 C Please describe your role.

Text field, <100 char
N Skip Logic Group OE_Role





Sheet 12: CQs v3 (EN) (12-10-13)

Model Instance Name:

red & strike-through: DELETE










SSA iClaim v3

underlined & italicized: RE-ORDER










MID: VgpBBYx9l8JxIFgJlY1Ikg4C

pink: ADDITION










Date: 7/15/2011 blue + -->: REWORDING













violet (bold): SKIP-LOGIC










SSA iClaim v3 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




ENBJL2230
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










ENBJL2231
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







Medicare only













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












Both Retirement and Disability













Spouse's M, Q, R, X, Y, Z, U, E, W












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












I am not applying today












Are you applying online for yourself or are you helping someone else? Myself
Dropdown (Select-one) Single Y
Applying for







Helping a Spouse/Relative/Friend













Professional Helping a Client













Other












How did you learn about this online application? (Select all that apply.) Official Social Security website
check box one up vertical Multi Y Skip Logic Group Learn about App







A general web search (e.g. Google, Bing, etc.)













The radio













The television













An email from Social Security













A newspaper or magazine article













An online ad (Banner/Image)













An online video













A newspaper or magazine ad













A billboard or other printed ad













Social Media (Blog, Facebook, Twitter, etc.)













Friend, spouse, relative, neighbor or acquaintance













Social Security statement













Social Security employee A












Community Group or Association













Other, please specify B










A How did you make contact with a Social Security employee? Visited a local Social Security office
check box one up vertical Multi Y Skip Logic SSA Emplyee Contact







Called a local Social Security office













Called the national 800 number













Other, please specify AA










AA Please describe how you made contact with a Social Security employee.

Text box, no char limit
N Skip Logic OPS SSA Employe Contact





B Please specify how you learned about this online application.

Text box, no char limit
N Skip Logic OPS Learn about App






Did you use any of the following to prepare to apply online? (Select all that apply.) Reviewed my online Social Security Statement A check box one up vertical Multi Y Skip Logic Prepare for App







I used the Retirement Estimator or other tools on the Social Security website B












I watched the instructional video C












I used other information on the Social Security website to prepare D












I used another resource to prepare to apply online E












I did not use any resources to prepare to apply online











A How helpful did you find the online Social Security Statement? Very helpful
Drop down select one Single Y Skip Logic Rate Statement







Somewhat helpful













Not at all helpful











B How helpful did you find the estimator tools on the website? Very helpful
Drop down select one Single Y Skip Logic Rate RE Tools







Somewhat helpful













Not at all helpful











C How helpful did you find the instructional video? Very helpful
Drop down select one Single Y Skip Logic Rate Video







Somewhat helpful













Not at all helpful











D How helpful did you find the other information on the Social Security website? Very helpful
Drop down select one Single Y Skip Logic Rate Other Info on Website







Somewhat helpful













Not at all helpful











E Please describe what other resource(s) you used to prepare to apply online?

Text field, no char limit
N Skip Logic OPS Prepare for App






Did you start a new online application today or did you return to a saved application? Started a new application
Drop down select one Single Y
App Status







Returned to work on a saved application












Did you complete and submit this online application today? Yes
Drop down select one Single Y Skip Logic Complete App







No, I plan to complete and submit later A












No, I do not plan to complete and submit the online application A










A If you did not complete and submit this online application today, please tell us why. Too many questions
check box one up vertical Multi Y Skip Logic Not Complete App







Takes too long to fill out













Too complicated to use without help













Didn't have information I needed like names, addresses, or dates













Didn't understand what questions meant/how to answer













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













I had a limited amount of time/family demands that kept me from working on it for very long













I had technical problems like an error message or a mistake I couldn't fix













Other, please specify AA










AA Please tell us why you did not complete and submit this application today.

Text field, no char limit
N Skip Logic OPS Why Not Complete today






So far, how long have you worked on this online application? Up to 15 minutes
Drop down select one Single Y
Time Spent







16 minutes - 30 minutes













31 minutes - 1 hour













More than 1 hour up to 2 hours













More than 2 hours












How easy was it for you to find this online application? Very easy




Find App







Somewhat easy













Somewhat hard A












Very hard A










A Please tell us why it was hard to find the online application. (Select all that apply.) Could not find where to start a new online application
check box one up vertical Multi Y Skip Logic Why hard to find







Not clear where to go to return to a previously saved application













It was not clear to me where the links would lead













Difficulty using a link on the Social Security website













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













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













I tried to use the FAQ's, but couldn't find the online application













Other reason (please describe) AA










AA Please explain the reason why it was hard for you to find the online application.

N
N Skip Logic OPS Hard to Find






How did you arrive at this online application today? Used the Online Services link on the Social Security homepage
Radio Button Single Y Skip Logic Arrive at App







Followed a link from somewhere else on the Social Security website













Used the search feature on the Social Security website













Used an outside search engine (i.e. Google, Bing, yahoo etc.)













Followed a link from medicare.gov













Followed a link from another website













Site was bookmarked













Other, please specify A










A Please describe how you arrived at this online application today

Text field, no char limit
N
OPS Arrive at app






Why did you choose to apply online? (Select all that apply.) I did not want to go to a local Social Security office
check box one up vertical Multi Y Skip Logic Why Online







I did not want to apply over the phone













I prefer to use online services as much as possible













I learned about applying online while visiting Social Security's website













A Social Security employee recommended that I apply online













A friend or relative recommended that I apply online













I knew that if I had a question or problem applying online, I could still get help from Social Security













I am filing on behalf of another person













Other, please specify A










A Please specify why you choose to apply online

Text field, no char limit
N
OPS Why Online






What is your current marital status? Married
Radio button, one-up vertical Single N OPS Group Marital Status






Separated













Divorced                   












Widowed                  












Never married          













Prefer not to answer













Other, please specify A










A Other marital status

Text field, <100 char
N OPS Group OPS Marital Status






Do you have any suggestions for improving Social Security's online application.

Text field, no char limit
N
OE_Improvement




ENBJL2232 M How did you learn about the Social Security online application? (Select all that apply.) Official Social Security website
Checkbox One Up Vertical Multi Y Skip Logic Group Learn About Online App



Types



A general web search (e.g. Google, Bing, etc.)













The radio













The television













An email from Social Security













A newspaper or magazine article













An online ad (Banner/Image)













An online video













A newspaper or magazine ad













A billboard or other printed ad













Social Media (Blog, Facebook, Twitter, etc.)













Friend, spouse, relative, neighbor or acquaintance













Social Security statement













Social Security employee B












Community Group or Association













Other, please specify A









ENBJL2233 A Please specify how you learned of Social Security online.

Text area, no char limit
N Skip Logic Group OE_Learn about online app




ENBJL2234 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









ENBJL2235 D Please describe the way you made contact with a social security employee.

Text field, <100 char
N Skip Logic Group OE_Contact SSA Employee




ENBJL2236 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










ENBJL2237 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










ENBJL2238 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









ENBJL2239 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




ENBJL2240 X Did you visit the Social Security home page (www.socialsecurity.gov) today? Yes
Dropdown (Select-one) Single Y Skip Logic Group Homepage







No










ENBJL2241 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










ENBJL2242 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









ENBJL2243 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









ENBJL2244 Z2 Please explain the reason you found it somewhat difficult to find the application.

Text area, no char limit
N Skip Logic Group OE_Difficult to Find




ENBJL2245 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










ENBJL2246 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










ENBJL2247 F What part of the instructions was not clear?

Text area, no char limit
N Skip Logic Group OE_Clarity of Instructions




ENBJL2248 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










ENBJL2249 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




ENBJL2250
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









ENBJL2251 B Please specify what influenced your decision to file for benefits online.

Text area, no char limit
N Skip Logic Group OE_Influenced Decision




ENBJL2252 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









ENBJL2253 C Please describe your role.

Text field, <100 char
N Skip Logic Group OE_Role





Sheet 13: v3 CQs (SP) (12-10-13)

Model Instance Name:

red & strike-through: DELETE










SSA iClaim v3 (Spanish)

underlined & italicized: RE-ORDER










MID: Q0ExM1xNQRl9JJUR0M0JlA4C
pink: ADDITION










Date: 7/15/2011 blue + -->: REWORDING













violet (bold): SKIP-LOGIC










SSA iClaim v3 (Spanish) 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




SPBJL2230
Por favor califique su impresión del nivel de seguridad al completar las tareas en esta solicitud. 1 = Decificente
Radio Button Scale Has Don’t Know Single Y
Level of Security































































































































Excelente = 10













No sé










SPBJL2231
¿Qué tipo de beneficios estaba solicitando? Por jubilación M, Q, R, X, Y, Z, U, E, W Dropdown (Select-one) Single Y Skip Logic Group Type of Benefits







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












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












Tanto Jubilación y Discapacidad













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












Otro













No estoy solicitando hoy












¿Es esta solicitud en línea para sí mismo o estás ayudando a alguien más? Yo mismo
Dropdown (Select-one) Single Y
Applying for







Cómo ayudar a un cónyuge / pariente / amigo













Profesional Ayudar a un cliente













Otro












¿Cómo se enteró acerca de esta solicitud en línea? (Seleccione todas las que apliquen.) Sitio web oficial de la Seguridad Social
check box one up vertical Multi Y Skip Logic Group Learn about App







Una búsqueda web general (por ejemplo, Google, Bing, etc)













La radio













La televisión













Un correo electrónico de la Seguridad Social













Un periódico o la revista













Un anuncio en línea (Banner / Imagen)













Un video en línea













Un periódico o una revista de anuncios













Un anuncio impreso cartelera u otro













Medios de Comunicación Social (Blog, Facebook, Twitter, etc)













Amigo, cónyuge, pariente, vecino o conocido













Declaración del Seguro Social













Empleado del Seguro Social A












Grupo de la comunidad o de la Asociación













Otro, especificar B










A ¿Cómo se hace el contacto con un empleado del Seguro Social? Visitado una oficina local del Seguro Social
check box one up vertical Multi Y Skip Logic SSA Emplyee Contact







Llamado a la oficina local del Seguro Social













Llamado el número nacional 800













Otro, especificar AA










AA Por favor describa cómo se hizo contacto con un empleado del Seguro Social.

Text box, no char limit
N Skip Logic OPS SSA Employe Contact





B Por favor, especifique cómo se enteró de esta aplicación en línea.

Text box, no char limit
N Skip Logic OPS Learn about App






¿Ha usado alguna de las siguientes acciones para prepararse para aplicar en línea? (Seleccione todas las que apliquen.) Comentado mi Declaración del Seguro Social en línea A check box one up vertical Multi Y Skip Logic Prepare for App







He utilizado el Retirement Estimator u otras herramientas en el sitio web de la Seguridad Social B












Vi el video de instrucciones C












Usé otra información en la página web de la Seguridad Social para preparar D












Utilicé otro recurso que se preparen para aplicar en línea E












No hice uso de los recursos para prepararse para aplicar en línea











A ¿Qué tan útil ha encontrado el Declaración del Seguro Social en línea? Muy útil
Drop down select one Single Y Skip Logic Rate Statement







algo útil













Para nada útil











B ¿Qué tan útil encontraste las herramientas estimador en el sitio web? Muy útil
Drop down select one Single Y Skip Logic Rate RE Tools







algo útil













Para nada útil











C ¿Qué tan útil le parecen la video instructivo? Muy útil
Drop down select one Single Y Skip Logic Rate Video







algo útil













Para nada útil











D ¿Qué tan útil le parecen la otra información en el sitio web de la Seguridad Social? Muy útil
Drop down select one Single Y Skip Logic Rate Other Info on Website







algo útil













Para nada útil











E Por favor describa lo otro recurso (s) que utilizó para prepararse para aplicar en línea.

Text field, no char limit
N Skip Logic OPS Prepare for App






¿Comenzó una nueva aplicación en línea hoy mismo o que te vuelva a una solicitud guardada? Comenzó una nueva aplicación
Drop down select one Single Y
App Status







Volvió a trabajar en una solicitud guardada












¿Sabía usted completar y presentar esta solicitud en línea hoy en día?
Drop down select one Single Y Skip Logic Complete App







No, tengo la intención de completar y enviar más tarde A












No, no tengo planes para completar y enviar la solicitud en línea A










A Si no logró completar y presentar esta solicitud en línea hoy, por favor díganos por qué. Demasiadas preguntas
check box one up vertical Multi Y Skip Logic Not Complete App







Toma demasiado tiempo para llenar













Demasiado complicado de usar sin ayuda













No tenía la información que necesitaba como nombres, direcciones o fechas













No entendía lo que significaba preguntas / cómo responder













Mi condición de discapacidad me impide trabajar con una computadora por largos periodos













Yo tenía una cantidad limitada de demandas de tiempo / de la familia que me impedía trabajar en ella por mucho tiempo













Tuve problemas técnicos, como un mensaje de error o un error que no podía fijar













Otro, especificar AA










AA Haznos saber por qué no se ha completado y se somete esta solicitud hoy.

Text field, no char limit
N Skip Logic OPS Why Not Complete today






Hasta el momento, ¿cuánto tiempo ha trabajado en esta solicitud en línea? Hasta 15 minutos
Drop down select one Single Y
Time Spent







16 minutos - 30 minutos













31 minutos - 1 hora













Más de 1 hora hasta 2 horas













Más de 2 horas












¿Fue fácil para usted para encontrar esta aplicación en línea? Muy fácil




Find App







algo fácil













algo duro A












Muy difícil A










A Haznos saber por qué era difícil encontrar la aplicación en línea. (Seleccione todas las que apliquen.) No se pudo encontrar por dónde empezar una nueva aplicación en línea
check box one up vertical Multi Y Skip Logic Why hard to find







Donde no está claro que vaya a volver a una solicitud previamente guardada













No estaba claro para mí cuando los vínculos conducirían













Dificultad para utilizar un enlace en la página web de la Seguridad Social













La información no parecía estar organizados de una manera lógica













Usé la función de búsqueda, pero los resultados no parecen aplicarse.













Traté de usar el FAQ, pero no pude encontrar la solicitud en línea













Otro, especificar AA










AA Por favor, explique la razón por la que era difícil para usted para encontrar la solicitud en línea.

N
N Skip Logic OPS Hard to Find






¿Cómo llegaste a esta solicitud en línea hoy en día? Se utiliza el enlace de los servicios en línea en la página web de la Seguridad Social
Radio Button Single Y Skip Logic Arrive at App







Seguido de un enlace de algún otro lugar en el sitio web de la Seguridad Social













Se utiliza la función de búsqueda en la página web de la Seguridad Social













Se utiliza un motor de búsqueda fuera (es decir, Google, Bing, Yahoo, etc)













Seguido de un enlace desde medicare.gov













Seguido un enlace desde otro sitio web













Este sitio fue bookmarked













Otro, especificar A










A Por favor describa cómo llegó a esta solicitud en línea hoy

Text field, no char limit
N
OPS Arrive at app






¿Por qué eligió para aplicar en línea? (Seleccione todas las que apliquen.) Yo no quería ir a una oficina local del Seguro Social
check box one up vertical Multi Y Skip Logic Why Online







Yo no quería que la solicitud por teléfono













Yo prefiero usar los servicios en línea tanto como sea posible













Aprendí acerca de la aplicación en línea durante su visita a la página web de la Seguridad Social













Un empleado del Seguro Social recomienda que aplico en línea













Un amigo o familiar recomendaron que aplico en línea













Yo sabía que si tenía alguna pregunta o problema la aplicación en línea, todavía podía recibir ayuda de la Seguridad Social













Estoy presentando en nombre de otra persona













Otro, especificar A










A Por favor, especifique qué decide aplicar en línea

Text field, no char limit
N
OPS Why Online






¿Cuál es su estado civil actual? casado
Radio button, one-up vertical Single N OPS Group Marital Status






apartado













divorciado













viudo












` Nunca se ha casado













Prefiero no responder













Otro, especificar A










A Otro estado civil

Text field, <100 char
N OPS Group OPS Marital Status






¿Tiene alguna sugerencia para mejorar la aplicación en línea de la Seguridad Social?

Text field, no char limit
N
OE_Improvement




SPBJL2232 M ¿Cómo se enteró de la solicitud por Internet del Seguro Social? (Seleccione todo lo que aplique.)  El sitio de Internet del Seguro Social
Checkbox One Up Vertical Multi Y Skip Logic Group Learn About Online App



Types



Una búsqueda por Internet (usando Google, Bing, etc.)













Una promoción en la radio













Una promoción en la televisión













Un e-mail del Seguro Social













Un artículo en un diario o una revista













Una  promoción por Internet (anuncio web/imagen)













Un video en la Internet













Una promoción en un diario o una revista













Una pancarta u otro tipo de promoción impresa 













En las redes sociales (un blog, en Facebook, Twitter, etc.) 













Un amigo, mi cónyuge, un familiar, un vecino o un conocido













La Declaración del Seguro Social













Un agente del Seguro Social B












Una asociación o un grupo comunitario













Otro modo, por favor especifique el modo A









SPBJL2233 A Por favor especifique cómo se enteró del sitio de Internet del Seguro Social.

Text area, no char limit
N Skip Logic Group OE_Learn about online app




SPBJL2234 B ¿Cómo se comunicó con un empleado del Seguro Social? Visitando una de las oficinas locales del Seguro Social
Radio Button One Up Vertical Single Y Skip Logic Group Contact SSA Employee







Llamando la oficina local del Seguro Social













Llamando el número 800 nacional













Otro modo, por favor especifique D









SPBJL2235 D Por favor describa la manera en la que se comunicó con un empleado del Seguro Social.

Text field, <100 char
N Skip Logic Group OE_Contact SSA Employee




SPBJL2236 Q ¿Completó la solicitud hoy? Sí, llené mi solicitud hoy mismo. C Radio Button One Up Vertical Single Y Skip Logic Group Complete App







Sí, reanudé y llené la solicitud que ya había comenzado. C












No, no terminé de llenar la solicitud pero la terminaré más adelante. C












No, no terminé de llenar la solicitud que ya había comenzado pero la terminaré más adelante. C












No, no tengo intención de terminar la solicitud. C












No voy a solicitar los beneficios hoy.










SPBJL2237 C ¿Para quién está llenando esta solicitud por Internet para beneficios de Seguro Social? Para mi mismo.
Radio Button One Up Vertical Single Y Skip Logic Group Whose Behalf







Para mi cónyuge.













Para mis padres.













Para un familiar.













Para un amigo.













Para un cliente.













Para otra persona










SPBJL2238 R Si dejó de llenar su solicitud, por favor díganos por qué. (Seleccione todo lo que aplique) Terminé de llenar mi solicitud hoy.
Checkbox One Up Vertical Multi Y Skip Logic Group Why Stopped App







Necesitaba conseguir algunos documentos u otra información para terminar mi solicitud.













Demasiadas preguntas













Me demoró mucho.













La solicitud es muy compllicada sin la ayuda de alguien.













Mi impedimento físico/médico me impide trabajar con una computadora por periodos prolongados.













La solicitud no aceptaba que dejara preguntas sin contestar.













Recibí un mensage haciendo saber que había sido «expulsado» de la solicitud.













Tuve problemas ingresando fechas y otra información en algunas de las páginas.













Por otras razones zz









SPBJL2239 zz Por favor díganos la razón por la que dejó de llenar su solicitud.

Text area, no char limit
N Skip Logic Group OE_Stopped Application




SPBJL2240 X ¿Visitó la página principal del Seguro Social (www.segurosocial.gov) hoy?
Dropdown (Select-one) Single Y Skip Logic Group Homepage







No










SPBJL2241 Y ¿Usó el encasillado de BUSCAR en nuestro sitio de Internet para encontrar lo que necesitaba?
Dropdown (Select-one) Single Y Skip Logic Group Search







No










SPBJL2242 Z Por favor díganos que tan fácil fue para que encontrara la solicitud para beneficios. Tuve un poco de dificultad para ingresar a la solicitud.
Radio Button One Up Vertical Single Y Skip Logic Group Find app







Se me hizo un poco dificultoso el encontrar la solicitud. Z1









SPBJL2243 Z1 Encontré que fue un poco difícil encontrar la solicitud debido a que: (Seleccione todo lo que aplique.) No sabía por dónde comenzar a buscar.
Checkbox One Up Vertical Multi Y Skip Logic Group Difficult to Find







No estaba claro a dónde me llevarían los enlaces.













No me pareción que la información estaba organizada en una manera lógica.













Usé la herramienta de búsqueda pero los resultados no parecían ser relevantes.













Por otras razones (por favor explique) Z2









SPBJL2244 Z2 Por favor explique la razón por la que encontró que la solicitud fue un poco difícil de encontrar.

Text area, no char limit
N Skip Logic Group OE_Difficult to Find




SPBJL2245 U ¿Cómo llegó al sitio de Internet del Seguro Social hoy? Ingresé la dirección ssa.gov o segurosocial.gov en el navegador de Internet.
Dropdown (Select-one) Single Y Skip Logic Group Arrive







Hice una búsqueda (usando Google, Bing, Yahoo)













Oprimí en un enlace que encontré en medicare.gov













Oprimí en un enlace que encontré en otro sitio de Internet.










SPBJL2246 E Por favor califique la claridad de las instrucciones provistas para esta solicitud por Internet del Seguro Social. 1 = No lo entiendo F Radio Button Scale Has Don’t Know Single Y Skip Logic Group Clarity of Instructions








F













F













F













F








































































Muy claro = 10













No sé










SPBJL2247 F ¿Qué parte de las instrucciones no estaban claras?

Text area, no char limit
N Skip Logic Group OE_Clarity of Instructions




SPBJL2248 G ¿Llenó el informe de incapacidad por Internet hoy? Sí.
Radio Button One Up Vertical Single Y Skip Logic Group Disability Report







No.













No me acuerdo.










SPBJL2249 W ¿Tiene algún otro problema con la solicitud por Internet del Seguro Social que no se cubrió en las preguntas anteriores, o alguna sugerencia sobre cómo podemos mejorarla? (Por favor no incluya ninguna información personal en su respuesta.)

Text area, no char limit
N Skip Logic Group Other Problems




SPBJL2250
¿Qué influyó su decisión para usar nuestra solicitud de beneficios por Internet? (Seleccione todo lo que aplique.) No quería ir a la oficina del Seguro Social.
Checkbox One Up Vertical Multi Y Skip Logic Group Influenced Decision Benefits







No quería transactar mis asuntos por teléfno.













Prefiero usar los servicio por Internet lo más posible.













Me informé acerca de los servicios por Internet al visitar el sitio de Internet segurosocialove













Uno de los agentes del Seguro Social sugirió el que solicitara los beneficios por Internet.













Un amigo, familiar o un colega sugirió el que solicitiara los beneficios por Internet.













Sabía que si tenía alguna pregunta podría llamar o visitar al Seguro Social.













Estoy llenando el formulario a nombre de otra persona. A












Otro razón, por favor especifique B









SPBJL2251 B Por favor especifique que influyó su decisión para solicitar los beneficios por Internet.

Text area, no char limit
N Skip Logic Group OE_Influenced Decision




SPBJL2252 A Por favor especifique el papel que desempeña: Proveo servicios como profesional sin fines de lucro.
Radio button, one-up vertical Single Y Skip Logic Group Role







Proveo servicios como profesional por honorario.













Soy un amigo o familiar del reclamante.













Otra persona, por favor especifique. C









SPBJL2253 C Por favor describa qué papel desempeña.

Text field, <100 char
N Skip Logic Group OE_Role





Sheet 14: v3 CQs (EE) (8-19-13)

Model Instance Name:

red & strike-through: DELETE










SSA iClaim v3

underlined & italicized: RE-ORDER










MID: xZAAEQw81gIo1Vo4Noc1Rw4C

pink: ADDITION










Date: 7/15/2011 blue + -->: REWORDING













violet (bold): SKIP-LOGIC










SSA iClaim v3 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




BJL2230
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










BJL2231
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










BJL2232 M How did you learn about the Social Security online application? (Select all that apply.) +-->Official Social Security website
Checkbox One Up Vertical Multi Y Skip Logic Group Learn About Online App



Types



A general web search (e.g. Google, Bing, etc.)













The radio













The television













An email from Social Security













A newspaper or magazine article













An online ad (Banner/Image)













An online video













A newspaper or magazine ad













A billboard or other printed ad













Social Media (Blog, Facebook, Twitter, etc.) B












Social Security statement













Social Security employee













Community Group or Association













Another website or search engine













News (TV, radio, newspaper or Internet)













Advertisement













Other, please specify A









BJL2233 A Please specify how you learned of Social Security online.

Text area, no char limit
N Skip Logic Group OE_Learn about online app




BJL2234 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









BJL2235 D Please describe the way you made contact with a social security employee.

Text field, <100 char
N Skip Logic Group OE_Contact SSA Employee




BJL2236 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










BJL2237 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










BJL2238 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









BJL2239 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




BJL2240 X Did you visit the Social Security home page (www.socialsecurity.gov) today? Yes
Dropdown (Select-one) Single Y Skip Logic Group Homepage







No










BJL2241 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










BJL2242 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









BJL2243 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









BJL2244 Z2 Please explain the reason you found it somewhat difficult to find the application.

Text area, no char limit
N Skip Logic Group OE_Difficult to Find




BJL2245 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










BJL2246 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










BJL2247 F What part of the instructions was not clear?

Text area, no char limit
N Skip Logic Group OE_Clarity of Instructions




BJL2248 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










BJL2249 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




BJL2250
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









BJL2251 B Please specify what influenced your decision to file for benefits online.

Text area, no char limit
N Skip Logic Group OE_Influenced Decision




BJL2252 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









BJL2253 C Please describe your role.

Text field, <100 char
N Skip Logic Group OE_Role





Sheet 15: CQs v3 (EN) (8-19-13)

Model Instance Name:

red & strike-through: DELETE










SSA iClaim v3

underlined & italicized: RE-ORDER










MID: VgpBBYx9l8JxIFgJlY1Ikg4C

pink: ADDITION










Date: 7/15/2011 blue + -->: REWORDING













violet (bold): SKIP-LOGIC










SSA iClaim v3 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




ENBJL2230
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










ENBJL2231
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










ENBJL2232 M How did you learn about the Social Security online application? (Select all that apply.) +-->Official Social Security website
Checkbox One Up Vertical Multi Y Skip Logic Group Learn About Online App



Types



A general web search (e.g. Google, Bing, etc.)













The radio













The television













An email from Social Security













A newspaper or magazine article













An online ad (Banner/Image)













An online video













A newspaper or magazine ad













A billboard or other printed ad













Social Media (Blog, Facebook, Twitter, etc.)













Social Security statement













Social Security employee B












Community Group or Association













Another website or search engine













News (TV, radio, newspaper or Internet)













Advertisement













Other, please specify A









ENBJL2233 A Please specify how you learned of Social Security online.

Text area, no char limit
N Skip Logic Group OE_Learn about online app




ENBJL2234 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









ENBJL2235 D Please describe the way you made contact with a social security employee.

Text field, <100 char
N Skip Logic Group OE_Contact SSA Employee




ENBJL2236 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










ENBJL2237 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










ENBJL2238 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









ENBJL2239 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




ENBJL2240 X Did you visit the Social Security home page (www.socialsecurity.gov) today? Yes
Dropdown (Select-one) Single Y Skip Logic Group Homepage







No










ENBJL2241 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










ENBJL2242 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









ENBJL2243 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









ENBJL2244 Z2 Please explain the reason you found it somewhat difficult to find the application.

Text area, no char limit
N Skip Logic Group OE_Difficult to Find




ENBJL2245 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










ENBJL2246 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










ENBJL2247 F What part of the instructions was not clear?

Text area, no char limit
N Skip Logic Group OE_Clarity of Instructions




ENBJL2248 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










ENBJL2249 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




ENBJL2250
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









ENBJL2251 B Please specify what influenced your decision to file for benefits online.

Text area, no char limit
N Skip Logic Group OE_Influenced Decision




ENBJL2252 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









ENBJL2253 C Please describe your role.

Text field, <100 char
N Skip Logic Group OE_Role





Sheet 16: v3 CQs (SP) (8-19-13)

Model Instance Name:

red & strike-through: DELETE











SSA iClaim v3 (Spanish)

underlined & italicized: RE-ORDER











MID: Q0ExM1xNQRl9JJUR0M0JlA4C
pink: ADDITION











Date: 7/15/2011 blue + -->: REWORDING














violet (bold): SKIP-LOGIC











SSA iClaim v3 (Spanish) 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




SPBJL2230
Por favor califique su impresión del nivel de seguridad al completar las tareas en esta solicitud. 1 = Decificente

Radio Button Scale Has Don’t Know Single Y
Level of Security







































































































































Excelente = 10














No sé











SPBJL2231
¿Qué tipo de beneficios estaba solicitando? Por jubilación
M, Q, R, X, Y, Z, U, E, W Dropdown (Select-one) Single Y Skip Logic Group Type of Benefits







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












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












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












No estoy solicitando hoy











SPBJL2232 M ¿Cómo se enteró de la solicitud por Internet del Seguro Social? (Seleccione todo lo que aplique.) El sitio de Internet del Seguro Social  El sitio de Internet del Seguro Social
Checkbox One Up Vertical Multi Y Skip Logic Group Learn About Online App



Types



Por un amigo, mi cónyuge, un familiar, un vecino o un conocido Una búsqueda por Internet (usando Google, Bing, etc.)













Agente del Seguro Social Una promoción en la radio B












Por medio de otro sitio de Internet o un buscador de internet Una promoción en la televisión













Las noticias (TV, radio, diario o Internet) Un e-mail del Seguro Social













Promoción Un artículo en un diario o una revista













La Declaración del Seguro Social Una  promoción por Internet (anuncio web/imagen)













Grupo o asociación comunitaria Un video en la Internet













Otro modo, por favor especifique Una promoción en un diario o una revista A













Una pancarta u otro tipo de promoción impresa 














En las redes sociales (un blog, en Facebook, Twitter, etc.) 














Un amigo, mi cónyuge, un familiar, un vecino o un conocido














La Declaración del Seguro Social














Un agente del Seguro Social














Una asociación o un grupo comunitario














Otro modo, por favor especifique el modo










SPBJL2233 A Por favor especifique cómo se enteró del sitio de Internet del Seguro Social.


Text area, no char limit
N Skip Logic Group OE_Learn about online app




SPBJL2234 B ¿Cómo se comunicó con un empleado del Seguro Social? Visitando una de las oficinas locales del Seguro Social

Radio Button One Up Vertical Single Y Skip Logic Group Contact SSA Employee







Llamando la oficina local del Seguro Social














Llamando el número 800 nacional














Otro modo, por favor especifique
D









SPBJL2235 D Por favor describa la manera en la que se comunicó con un empleado del Seguro Social.


Text field, <100 char
N Skip Logic Group OE_Contact SSA Employee




SPBJL2236 Q ¿Completó la solicitud hoy? Sí, llené mi solicitud hoy mismo.
C Radio Button One Up Vertical Single Y Skip Logic Group Complete App







Sí, reanudé y llené la solicitud que ya había comenzado.
C












No, no terminé de llenar la solicitud pero la terminaré más adelante.
C












No, no terminé de llenar la solicitud que ya había comenzado pero la terminaré más adelante.
C












No, no tengo intención de terminar la solicitud.
C












No voy a solicitar los beneficios hoy.











SPBJL2237 C ¿Para quién está llenando esta solicitud por Internet para beneficios de Seguro Social? Para mi mismo.

Radio Button One Up Vertical Single Y Skip Logic Group Whose Behalf







Para mi cónyuge.














Para mis padres.














Para un familiar.














Para un amigo.














Para un cliente.














Para otra persona











SPBJL2238 R Si dejó de llenar su solicitud, por favor díganos por qué. (Seleccione todo lo que aplique) Terminé de llenar mi solicitud hoy.

Checkbox One Up Vertical Multi Y Skip Logic Group Why Stopped App







Necesitaba conseguir algunos documentos u otra información para terminar mi solicitud.














Demasiadas preguntas














Me demoró mucho.














La solicitud es muy compllicada sin la ayuda de alguien.














Mi impedimento físico/médico me impide trabajar con una computadora por periodos prolongados.














La solicitud no aceptaba que dejara preguntas sin contestar.














Recibí un mensage haciendo saber que había sido «expulsado» de la solicitud.














Tuve problemas ingresando fechas y otra información en algunas de las páginas.














Por otras razones
zz









SPBJL2239 zz Por favor díganos la razón por la que dejó de llenar su solicitud.


Text area, no char limit
N Skip Logic Group OE_Stopped Application




SPBJL2240 X ¿Visitó la página principal del Seguro Social (www.segurosocial.gov) hoy?

Dropdown (Select-one) Single Y Skip Logic Group Homepage







No











SPBJL2241 Y ¿Usó el encasillado de BUSCAR en nuestro sitio de Internet para encontrar lo que necesitaba?

Dropdown (Select-one) Single Y Skip Logic Group Search







No











SPBJL2242 Z Por favor díganos que tan fácil fue para que encontrara la solicitud para beneficios. Tuve un poco de dificultad para ingresar a la solicitud.

Radio Button One Up Vertical Single Y Skip Logic Group Find app







Se me hizo un poco dificultoso el encontrar la solicitud.
Z1









SPBJL2243 Z1 Encontré que fue un poco difícil encontrar la solicitud debido a que: (Seleccione todo lo que aplique.) No sabía por dónde comenzar a buscar.

Checkbox One Up Vertical Multi Y Skip Logic Group Difficult to Find







No estaba claro a dónde me llevarían los enlaces.














No me pareción que la información estaba organizada en una manera lógica.














Usé la herramienta de búsqueda pero los resultados no parecían ser relevantes.














Por otras razones (por favor explique)
Z2









SPBJL2244 Z2 Por favor explique la razón por la que encontró que la solicitud fue un poco difícil de encontrar.


Text area, no char limit
N Skip Logic Group OE_Difficult to Find




SPBJL2245 U ¿Cómo llegó al sitio de Internet del Seguro Social hoy? Ingresé la dirección ssa.gov o segurosocial.gov en el navegador de Internet.

Dropdown (Select-one) Single Y Skip Logic Group Arrive







Hice una búsqueda (usando Google, Bing, Yahoo)














Oprimí en un enlace que encontré en medicare.gov














Oprimí en un enlace que encontré en otro sitio de Internet.











SPBJL2246 E Por favor califique la claridad de las instrucciones provistas para esta solicitud por Internet del Seguro Social. 1 = No lo entiendo
F Radio Button Scale Has Don’t Know Single Y Skip Logic Group Clarity of Instructions









F














F














F














F












































































Muy claro = 10














No sé











SPBJL2247 F ¿Qué parte de las instrucciones no estaban claras?


Text area, no char limit
N Skip Logic Group OE_Clarity of Instructions




SPBJL2248 G ¿Llenó el informe de incapacidad por Internet hoy? Sí.

Radio Button One Up Vertical Single Y Skip Logic Group Disability Report







No.














No me acuerdo.











SPBJL2249 W ¿Tiene algún otro problema con la solicitud por Internet del Seguro Social que no se cubrió en las preguntas anteriores, o alguna sugerencia sobre cómo podemos mejorarla? (Por favor no incluya ninguna información personal en su respuesta.)


Text area, no char limit
N Skip Logic Group Other Problems




SPBJL2250
¿Qué influyó su decisión para usar nuestra solicitud de beneficios por Internet? (Seleccione todo lo que aplique.) No quería ir a la oficina del Seguro Social.

Checkbox One Up Vertical Multi Y Skip Logic Group Influenced Decision Benefits







No quería transactar mis asuntos por teléfno.














Prefiero usar los servicio por Internet lo más posible.














Me informé acerca de los servicios por Internet al visitar el sitio de Internet segurosocialove














Uno de los agentes del Seguro Social sugirió el que solicitara los beneficios por Internet.














Un amigo, familiar o un colega sugirió el que solicitiara los beneficios por Internet.














Sabía que si tenía alguna pregunta podría llamar o visitar al Seguro Social.














Estoy llenando el formulario a nombre de otra persona.
A












Otro razón, por favor especifique
B









SPBJL2251 B Por favor especifique que influyó su decisión para solicitar los beneficios por Internet.


Text area, no char limit
N Skip Logic Group OE_Influenced Decision




SPBJL2252 A Por favor especifique el papel que desempeña: Proveo servicios como profesional sin fines de lucro.

Radio button, one-up vertical Single Y Skip Logic Group Role







Proveo servicios como profesional por honorario.














Soy un amigo o familiar del reclamante.














Otra persona, por favor especifique.
C









SPBJL2253 C Por favor describa qué papel desempeña.


Text field, <100 char
N Skip Logic Group OE_Role




File Typeapplication/vnd.openxmlformats-officedocument.spreadsheetml.sheet
File Modified0000-00-00
File Created0000-00-00

© 2024 OMB.report | Privacy Policy