Ticket To Work Employment Network Customer Satisfaction Survey

OMB Control No. 0960-0526

Expiration Date: November 2015

CONSUMER SATISFACTION SURVEY

YOUR HELP IS VERY IMPORTANT! This survey has been mailed to Social Security Administration beneficiaries who have assigned their tickets to an Employment Network under the Ticket to Work program. The questions below will be used to provide information on Employment Networks. The Employment Network’s staff will not see your answers. Your Employment Network is <INSERT EN>.

Please answer every question. If you are not sure of an exact answer, please give your best guess. If you are a representative payee answering on behalf of a beneficiary, fill out the survey to the best of your ability to reflect the opinions of the beneficiary.

If you would prefer to complete the survey online, instead of on paper, please go to:

http://www.eurekafacts.com/ttw

You will be asked for a PIN number. Your PIN number is [abc123]

If you have any questions about this survey, you may call EurekaFacts at 1-855-403-4800 or email to [email protected]. TDD/TTY users please contact your local Relay Center.

Thank you very much for your help in improving the Ticket to Work program.

_______________________________________________________________________________________________________

Paperwork Reduction Act Statement

Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C. §3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 10 minutes to complete this survey. You may send comments on our time estimate above: SSA, 6401 Security Blvd., Baltimore, MD  21235-6401. Send only comments relating to our time estimate to this address.

Send the completed questionnaire to:

Ticket to Work Survey

451 Hungerford Drive (Rockville Pike), Suite 515

Rockville, Maryland, 20850

If you completed the survey online, you do not need to send the paper questionnaire.

_______________________________________________________________________________________________________

About Your Employment Network

Please rate your level of satisfaction with the following aspects of your Employment Network. If you are a representative payee answering on behalf of a beneficiary, please choose the level of satisfaction you believe the beneficiary has with the following aspects of his or her Employment Network.

1. The ability of staff members at my Employment Network to support me.

__ Completely Satisfied

__ Somewhat Satisfied

__ Neither Satisfied or Dissatisfied

__ Somewhat Dissatisfied

__ Completely Dissatisfied

2. The ability of my Employment Network to help me understand the types of jobs available in my community.

__ Completely Satisfied

__ Somewhat Satisfied

__ Neither Satisfied or Dissatisfied

__ Somewhat Dissatisfied

__ Completely Dissatisfied

3. The types of services provided by my Employment Network to help me meet my individual goals.

__ Completely Satisfied

__ Somewhat Satisfied

__ Neither Satisfied or Dissatisfied

__ Somewhat Dissatisfied

__ Completely Dissatisfied

4. The knowledge of staff members I interacted with at my Employment Network.

__ Completely Satisfied

__ Somewhat Satisfied

__ Neither Satisfied or Dissatisfied

__ Somewhat Dissatisfied

__ Completely Dissatisfied

5. The usefulness of the services from my Employment Network in helping me meet my employment goals.

__ Completely Satisfied

__ Somewhat Satisfied

__ Neither Satisfied or Dissatisfied

__ Somewhat Dissatisfied

__ Completely Dissatisfied

6. The respectfulness of the staff at my Employment Network.

__ Completely Satisfied

__ Somewhat Satisfied

__ Neither Satisfied or Dissatisfied

__ Somewhat Dissatisfied

__ Completely Dissatisfied

7. The information my Employment Network gave me about other agencies in my community that could help me reach my employment goal.

__ Completely Satisfied

__ Somewhat Satisfied

__ Neither Satisfied or Dissatisfied

__ Somewhat Dissatisfied

__ Completely Dissatisfied

8. My overall satisfaction with my Employment Network.

__ Completely Satisfied

__ Somewhat Satisfied

__ Neither Satisfied or Dissatisfied

__ Somewhat Dissatisfied

__ Completely Dissatisfied

9. When you signed up with your Employment Network, what did your Employment Network explain to you about their role in helping you find a job?

(Please check all that apply.)

_____ The Employment Network would help me with career planning.

_____ The Employment Network would provide services to help me find a job.

_____ The Employment Network would provide services to help me keep a job.

_____ The Employment Network would guarantee that I would find a job.

Other (please specify) _____________________________________________________

10. Please indicate what services you and your Employment Network agreed you needed, and then indicate what services you actually received from your Employment Network?

(Please check all that apply.)

	Services you needed.	Services you received.
Career Planning
Job coaching/training
Job placement
Ongoing support to help you keep the job
Help obtaining services from other organizations
Work incentive counseling or referral for work-incentive counseling
Other (Please specify in the boxes to the right)	_________________	_________________

­

11. Please indicate which of the following areas you liked about your Employment Network and which of the following areas you think need to improve.

(Please check all that apply. It is okay to check both boxes or not check either box)

	Areas I liked	Areas I think need to improve
Location
Quality of Services
Amount of time waiting for follow-up services
Information in accessible formats (e.g., Braille, online, print, another language)
Hours of operation
Responsiveness of staff in returning phone calls and emails
Other (Please specify in the boxes to the right)	_____________	_______________

ABOUT YOUR JOB

12. Are you currently employed?

__ Yes Continue to Q 13

__ No  Go to Q 18

13. When did you begin working at your current job?

(Please select one option)

___ Within the last three months

___ 3 - 6 months ago

___ 7 - 9 months ago

___ 10 - 12 months ago

___ More than 12 months ago

14. About how many hours a week do you normally work at your current job?

___ hours per week (Example: 32 hours)

15. Did your Employment Network provide services that helped you get your current job?

__ Yes

__ No

16. Does your current job provide you with or offer you any of these benefits?

(Please check all that apply.)

__ Paid vacation

__ Paid sick leave

__ Medical insurance

__ Dental insurance

__ Retirement plan

17. What is your annual salary at your current position before taxes and benefits?

__ $1 - $19,999

__ $20,000 - $39,999

__ $40,000 - $59,999

__ $60,000 - $79,999

__ $80,000 - $99,999

__ $100,000 or more

__ Volunteer/Unpaid

COMMENTS

18. What ideas do you have for improving the Ticket to Work Program? (Please be specific.) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________