Five Quanitative Customer Satisfaction Surveys

Generic Clearance of Customer Satisfaction Surveys

Survey Instrument 2014 DICRC Questionnaires and Correspondence

Five Quanitative Customer Satisfaction Surveys

OMB: 0960-0526

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0960-0526 can be found here:

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Disability Initial Claims Report Card – First Survey Interval (Mid-Process) Questionnaire– English

Social Security Survey
Social Security is committed to improving the service we provide the public. Please complete this
questionnaire to give us your opinion of the service you recently received when you filed for disability benefits.
MARKING INSTRUCTIONS
Correct Marking Example: X
• Use blue or black pen or a number 2 pencil.
• Make no stray marks.
• Do not use pens with ink that soaks through the paper.
• Keep all entries within the boxes.
1.

How did you file your application for disability benefits?
(If you used more than one way, please check the main way.) Mark [X] only ONE.





Did anyone besides Social Security help you with your application? Mark [X] only ONE.



In person with a Social Security employee
Over the telephone with a Social Security employee
On Social Security’s Internet website (www.socialsecurity.gov)
Someone else did it for me

Please tell us who helped you:







 Go to question 4.
 Go to question 3.

No, I did it by myself with the help of a Social Security employee ONLY.
Yes, I had help from someone other than a Social Security employee.
Mark [X] all that apply.

A husband, wife, relative or friend
A state or local government agency (such as your social worker or case worker)
A nonprofit organization that serves people with disabilities
(such as the United Cerebral Palsy Association)
An attorney or a paid professional disability consulting service
A health care provider
Other (such as your employer, school or church)

Excellent

Very Good

Good

Fair

Poor

Very Poor

Not
Applicable

Please use the scale shown to rate the following aspects of your experience filing for disability benefits.

Ease of finding information about how to apply for disability
benefits.

N/A

Quality of information you got about how to apply for
disability benefits.

N/A

Ease of working with Social Security to start the application
process.

N/A

If a question does not apply to you, please
mark Not Applicable.
Mark [X] ONE rating for every item.
When you decided to file…

PLEASE CONTINUE TO PAGE 2

Excellent

Very Good

Good

Fair

Poor

Very Poor

Not
Applicable

Please use the scale shown to rate the following aspects of your experience filing for disability benefits.

Information and documents you needed for your application.

N/A

Requirements for getting disability benefits and how you
qualify.

N/A

How the disability application process works, for example
who makes the decision and how long it takes.

N/A

10. Ease of answering questions about your medical condition
and treatment.

N/A

11. Ease of answering questions about the work you did in the
past.

N/A

12. Ease of answering questions about your education and job
training.

N/A

13. Helpfulness of the staff.

N/A

14. Courtesy of the staff.

N/A

15. How well the staff knew their jobs.

N/A

16. How clearly the staff explained things to you.

N/A

17. The amount of time the staff spent with you.

N/A

18. Ease of filing your disability application with
Social Security.

N/A

19. Overall opinion of Social Security’s service.

N/A

If a question does not apply to you, please
mark Not Applicable.
Mark [X] ONE rating for every item.
Explanations Social Security gave you about…

Providing information to Social Security…

How Social Security employees did their job…

Your overall experience…

PLEASE CONTINUE TO PAGE 3

A little more about you…
20. When you do business with Social Security, in person, on the telephone, or online, do you need them to provide
any special accommodations because of a medical condition?
Mark [X] ONE answer.
 Yes



 SKIP to Question 23.

21. Do you need special accommodations because of a:
Mark [X] all that apply.
 Physical limitation (for example, wheelchair access)
 Visual limitation (for example, large print or Braille documents)
 Deafness or difficulty hearing (for example, sign language interpreter or video relay)
 Other limitation (for example, a learning disability)
22. How satisfied are you with how well Social Security meets your need for special accommodations? Are you:
Mark [X] ONE answer.
 Very satisfied
 Somewhat satisfied
 Somewhat dissatisfied, or
 Very dissatisfied
23. Please use this space to explain any of your answers, especially any reasons for dissatisfaction, or to provide any
other comments about the service you received when you filed your application for disability benefits.

OMB Control N0. 0960-0526 Expiration Date: November 2015

Disability Initial Claims Report Card – Second and Third Survey (Post-Adjudicative) Interval Questionnaire – English

How did you file your application for disability benefits?
(If you used more than one way, please check the main way.) Mark [X] only ONE.





Did anyone besides Social Security help you with your application? Mark [X] only ONE.



In person with a Social Security employee
Over the telephone with a Social Security employee
On Social Security’s Internet website (www.socialsecurity.gov)
Someone else did it for me

Please tell us who helped you:







 Go to question 4.
 Go to question 3.

No, I did it by myself with the help of a Social Security employee ONLY.
Yes, I had help from someone other than a Social Security employee.
Mark [X] all that apply.

Excellent

Very Good

Good

Fair

Poor

Very Poor

Not
Applicable

Please use the scale shown to rate the following aspects of your experience filing for disability benefits.

Ease of answering questions about your disability.

N/A

Ease of obtaining your own medical records, if you did so.

N/A

Experience during any medical examination or test
Social Security sent you to.

N/A

If a question does not apply to you, please
mark Not Applicable.
Mark [X] ONE rating for every item.
Providing medical information…

PLEASE CONTINUE TO PAGE 2

Excellent

Very Good

Good

Fair

Poor

Very Poor

Not
Applicable

Please use the scale shown to rate the following aspects of your experience filing for disability benefits.

Ease of contacting Social Security for status of your
application.

N/A

Usefulness of information Social Security gave you about
the status.

N/A

10. Courtesy of the staff.

N/A

11. How well the staff knew their jobs.

N/A

12. How clearly the staff explained things to you.

N/A

13. The amount of time the staff spent with you.

N/A

14. Length of time it took Social Security to handle
your application.

N/A

15. Clarity of the letter explaining Social Security’s decision on
your application.

N/A

16. Ease of filing your disability application with
Social Security.

N/A

17. Overall opinion of Social Security’s service.

N/A

If a question does not apply to you, please
mark Not Applicable.
Mark [X] ONE rating for every item.
Finding out what was happening on your application…

How Social Security employees did their job…
9.

Helpfulness of the staff.

Getting the decision on your application…

Your overall experience…

PLEASE CONTINUE TO PAGE 3

A little more about you…
18. When you do business with Social Security, in person, on the telephone, or online, do you need them to provide
any special accommodations because of a medical condition?
Mark [X] ONE answer.
 Yes



 SKIP to Question 21.

19. Do you need special accommodations because of a:
Mark [X] all that apply.
 Physical limitation (for example, wheelchair access)
 Visual limitation (for example, large print or Braille documents)
 Deafness or difficulty hearing (for example, sign language interpreter or video relay)
 Other limitation (for example, a learning disability)
20. How satisfied are you with how well Social Security meets your need for special accommodations? Are you:
Mark [X] ONE answer.
 Very satisfied
 Somewhat satisfied
 Somewhat dissatisfied, or
 Very dissatisfied
21. Please use this space to explain any of your answers, especially any reasons for dissatisfaction, or to provide any
other comments about the service you received when you filed your application for disability benefits.

OMB Control N0. 0960-0526 Expiration Date: November 2015

FY 2014 DICRC SURVEY
PRENOTICE POSTCARD

Dear Social Security Applicant:
Social Security believes that conducting surveys is one of the best ways to find out how well we
are serving you. That’s why we will soon be asking you to give us your opinion about the
service you received for your recent business with Social Security.
In a few days, you will receive a short questionnaire in the mail from [Contractor], who is
conducting this survey for Social Security. When you receive their envelope, we hope that you
will take the time to answer our questions and tell us what you think of our service.
We look forward to hearing your opinions.

Social Security Administration

FY 2014 DICRC SURVEY
INITIAL COVER LETTER

Dear Social Security Applicant:
As I noted in my recent postcard, Social Security is conducting a survey to get your opinion of
the service you received when you filed an application for Social Security disability benefits.
The survey is short and should only take 5 minutes to complete. Please take a few minutes now
to answer the questions and return the form as soon as possible in the postage-paid envelope
provided. While you are not required to respond, your opinions are very important to us and we
would like to hear from as many people as possible. Please do not put any information related
to your Social Security business in the envelope with your completed survey.
Please be assured that [insert contractor name], who is conducting this survey for us, will only
give your responses to my staff here at Social Security and will not use them for any other
purpose. Social Security will report the survey results by summarizing the answers of everyone
who takes the survey; we will not report any individual responses. Your participation in this
survey will not affect your eligibility for benefits or any business you have with Social Security.
If you have any questions about your application or benefits, please call Social Security’s tollfree information line at 1-800-772-1213 or visit our web site at www.socialsecurity.gov.
Thank you for sharing your opinions with us.
Sincerely,

Social Security Administration

FY 2014 DICRC SURVEY
FOLLOW-UP POSTCARD

Dear Social Security Applicant:
About two weeks ago we sent you a survey form asking for your opinion of the service you
received for your recent business with Social Security.
•
•
•

If you have already mailed back your completed survey, thank you for your
quick response.
If not, please take 5 minutes now to complete and return the survey in the
postage-paid envelope provided.
If you no longer have the survey, you don’t need to do anything. [Contractor],
who is conducting the survey for us, will be mailing another form to you shortly.

Thank you for your help with this survey.

Social Security Administration

FY 2014 DICRC SURVEY
FOLLOW-UP COVER LETTER

Dear Social Security Applicant:
About a month ago we sent you a brief survey asking about the service you received when you
filed an application for Social Security disability benefits. We haven’t yet heard from you and
it’s important that we gather opinions from as many people as possible.
If you recently mailed in your completed survey form, please discard this letter. We sincerely
appreciate your help and we look forward to receiving your response. However, if you have not
yet returned the survey, please take 5 minutes now to complete it and send it back. For your
convenience, we have enclosed another copy along with a postage-paid return envelope. Please
do not put any information related to your Social Security business in the envelope with
your completed survey.
Please be assured that [Contractor], who is conducting this survey for us, will only give your
responses to the staff here at Social Security and will not use them for any other purpose. Social
Security will report the survey results by summarizing the answers of everyone who takes the
survey; we will not report any individual responses. Your participation in this survey will not
affect your eligibility for benefits or any business you have with Social Security.
If you have any questions about your hearing request or benefits, please call Social Security’s
toll-free information line at 1-800-772-1213 or visit our web site at www.socialsecurity.gov.
We would appreciate receiving your completed survey as soon as possible.
Sincerely,

Social Security Administration

PRIVACY ACT STATEMENT
The Social Security Administration is authorized to collect the information for this survey under
Executive Order 12862, “Setting Customer Service Standards.” Your response to these
questions is strictly voluntary. The information you provide will be used to help us improve the
service that we give you. Your response will not be disclosed to any other government or private
agency.

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 5 minutes to read the instructions, gather the facts, and answer the questions. You
may send comments on our time estimate above to: Social Security Administration,
6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.

File Type	application/pdf
Author	dpse
File Modified	2013-08-19
File Created	2013-08-19