Five Quanitative Customer Satisfaction Surveys

Give Social Security a Report Card...
Please answer the following questions to give us your opinion of the online application you recently
completed on Social Security’s website.
MARKING INSTRUCTIONS
Correct Marking Example: 
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Use blue or black pen or a number 2 pencil.
Do not use pens with ink that soaks through the paper.

1.

How did you hear about Social Security’s online application?

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Make no stray marks.
Keep all entries within the boxes.
Mark all that apply.

From Social Security (an employee, their website, written material, etc.)
From a family member or friend
From an Internet search engine or website other than Social Security’s
From online social media (Facebook, Twitter, etc.)
From traditional media (newspaper, magazine, TV or radio, etc.)
From a doctor or other health care professional, social worker
From a nonprofit organization that serves the aged or people with disabilities (United Cerebral
Palsy, ARC, etc.)

□ From an attorney or a paid professional consulting service (Allsup, Binder & Binder, etc.)
□ Somewhere else (employer, union, school, church, etc.)
2.

Did you fill out the online application by yourself or was someone else there to help you with it?
Mark only ONE answer.

□ Filled it out by myself
 Please skip to question 4.
□ Someone else helped me  Please continue with question 3.
3. Who helped you?

Mark only ONE answer.

□ Non-professional (family member, friend, etc.)
□ Professional (attorney, social worker, doctor, etc.)

Good

Fair

Poor

Very Poor

Not
Applicable

When you decided to file online…
4. Ease of finding the online application on Social Security’s
website
5. Number of pages you went through before you could start the
online application
6. Appearance of the online application pages (amount of
information, how the information is arranged, etc.)
7. How well Social Security’s website explained what information
and documents you needed to complete your online application

Very Good

Mark [X] ONE answer for every item.

Excellent

Please use the scale shown to rate the following aspects of your experience using Social Security’s online
application. If a question does not apply to you, please mark Not Applicable.

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PLEASE CONTINUE TO PAGE 2

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Very Good

Good

Fair

Poor

Very Poor

Not
Applicable

Ease of answering the questions on the online application

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Helpfulness of the explanations in the “More Info” links on the
online application
10. Availability of other help from Social Security to complete the
online application

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11. Length of time it took to complete the online application

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Mark [X] ONE answer for every item.

Completing the online application…
8.
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12. About how long did it take you complete the online application?
15 minutes or less
Over 15 and up to 30 minutes
Over 30 and up to 45 minutes
Over 45 and up to 1 hour
Over 1 hour and up to 2 hours

Very Good

Good

Fair

Poor

Very Poor

Not
Applicable

More than 2 hours
Excellent

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Mark only ONE answer.

13. What would happen after you submitted your online application

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14. Other information you needed to know about your benefits

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15. The security and privacy policies of the website

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16. Overall opinion of Social Security’s online application

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Mark [X] ONE answer for every item.

Mark [X] ONE answer for every item.

Explanations on Social Security’s website about…

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Likely

Somewhat
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Not at all
Likely

Not
Applicable

Your overall rating…

17. Recommend Social Security’s online application to others

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18. Use Social Security’s website for your future business (request
information, change your address, etc.)
19. Use a handheld mobile device (smartphone, iPad, etc.) to do
business on Social Security’s website

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Your likelihood to…

Your need for special accommodations…
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] only ONE answer.
(Answer question 21 and tell us what special accommodations you need in question 22.)

Not
Applicable

Very
Dissatisfied

Somewhat
Dissatisfied

Mark [X] only ONE answer.

Somewhat
Satisfied

(Skip to question 22.)
Very
Satisfied

□ Yes
□ No

21. How satisfied are you with how well Social Security meets your
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need for special accommodations?
22. Please use this space to provide any comments you may have about Social Security’s online application or to
explain any of your answers.

OMB Control Number 0960-0526; Expiration Date: November 2015

Thank you for taking the time to rate Social Security!
Please send us your “Report Card” in the enclosed postage-paid envelope as soon as possible.

Give Social Security a Report Card...
Please give us your opinion of the online disability form you recently completed on Social Security’s
website to file an application for disability benefits or to request a disability appeal.
MARKING INSTRUCTIONS
Correct Marking Example: 
•
•
1.

Use blue or black pen or a number 2 pencil.
Do not use pens with ink that soaks through the paper.

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How did you hear about completing the disability form online?

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Make no stray marks.
Keep all entries within the boxes.
Mark all that apply.

From Social Security (an employee, their website, written material, etc.)
From a family member or friend
From an Internet search engine or website other than Social Security’s
From online social media (Facebook, Twitter, etc.)
From traditional media (newspaper, magazine, TV or radio, etc.)
From a doctor or other health care professional, social worker
From a nonprofit organization that serves the aged or people with disabilities (United Cerebral
Palsy, ARC, etc.)

□ From an attorney or a paid professional consulting service (Allsup, Binder & Binder, etc.)
□ Somewhere else (employer, union, school, church, etc.)
2. Did you fill out the online disability form by yourself or was someone else there to help you with it?
Mark only ONE answer.

□ Filled it out by myself
□ Someone else helped me

Excellent

Very Good

Good

Fair

Poor

Very Poor

Not
Applicable

Please use the scale shown to rate the following aspects of your experience using Social Security’s online
disability application or appeal. If a question does not apply to you, please mark Not Applicable.

3.

Ease of finding the online form on Social Security’s website

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4.

Number of pages you went through before you could start
the online form

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5.

How well Social Security’s website explained how the
online form works

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How well Social Security’s website explained what
information you needed to complete the online form

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Appearance of the online pages (amount of information,
how the information is arranged, etc.)

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Mark [X] ONE answer for every item.

Starting the online disability application or appeal…

PLEASE CONTINUE TO PAGE 2

Completing the online disability application or
appeal …
8. Did you complete the online form in one or more than one sitting? Mark only ONE answer.
 Please skip to question 10.

Mark [X] ONE answer for every item.

Very Good

Good

Fair

Poor

Very Poor

Not
Applicable

 Please continue with question 9.
Excellent

□ One sitting
□ More than one sitting

9.

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Ease of getting back to the online form you started earlier

10. Length of time it took to complete the online form

11. About how long did it take you complete the online form? Mark only ONE answer.
1 hour or less
Over 1 hour and up to 2 hours
Over 2 hours and up to 3 hours

Not
Applicable

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13. Ease of providing the information requested on the online
form

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14. Helpfulness of the examples and explanations in the links
on the online form

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15. Availability of other help from Social Security to
complete the online form

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Not
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Very Poor

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Very Poor

Poor

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Poor

Fair

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Fair

Good

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Good

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Very Good

12. Ease of understanding the questions on the online form

Excellent

Mark [X] ONE answer for every item.

Very Good

Over 3 hours
Excellent

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Explanations on Social Security’s website about…
16. What would happen after you submitted the online
disability application or appeal

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17. The security and privacy policies of the website

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Your overall rating…
18. Overall opinion of Social Security’s online disability
application or appeal

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Mark [X] ONE answer for every item.

Very
Likely

Somewhat
Likely

Not very
Likely

Not at all
Likely

Not
Applicable

19. Recommend Social Security’s website to others

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20. Use Social Security’s website for future business (look for
information, etc.)
21. Use a handheld mobile device (smartphone, iPad, etc.) to do
business on Social Security’s website
Your need for special accommodations…

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Mark [X] ONE answer for every item.

Your likelihood to…

22. 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] only ONE answer.
(Answer question 23 and tell us what special accommodations you need in question 24.)

23. How satisfied are you with how well Social Security
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meets your need for special accommodations?
24. Please use this space to provide any comments you may have about Social Security’s online Disability
Report or to explain any of your answers.

OMB Control Number 0960-0526; Expiration Date: November 2015

Thank you for taking the time to rate Social Security!
Please send us your “Report Card” in the enclosed postage-paid envelope as soon as possible.

Not
Applicable

Very
Dissatisfied

Somewhat
Dissatisfied

Mark [X] only ONE answer.

Somewhat
Satisfied

(Skip to question 24.)
Very
Satisfied

□ Yes
□ No

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Give Social Security a Report Card...
Social Security’s records show that you recently used Social Security’s website to:
- obtain a proof of income letter (verify your payment amount, payment date, etc.), OR
request a replacement SSA-1099 (statement of total benefits paid for tax purposes), OR
request a replacement Medicare card.
Please answer the following questions to give us your opinion of the online service you used.
MARKING INSTRUCTIONS
Correct Marking Example: 
•
•
1.

• Make no stray marks.
• Keep all entries within the boxes.
How did you hear about the service on Social Security’s website? Mark [X] all that apply.
Use blue or black pen or a number 2 pencil.
Do not use pens with ink that soaks through the paper.

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From Social Security (an employee, their website, written material, etc.)
From a family member or friend
From an Internet search engine or website other than Social Security’s
From a doctor, pharmacist or other health care professional, social worker
From a nonprofit organization that serves the aged or people with disabilities (United Cerebral
Palsy, etc.)

□ From traditional media (newspaper, magazine, TV or radio, etc.)
□ From online social media (Facebook, Twitter, etc.)
□ Somewhere else (accountant, school, church, etc.)
2.

Did you complete the online request by yourself or was someone else there to help you?
Mark [X] only ONE answer.

□ Completed it by myself
□ Someone else helped me
3.

Who helped you?

 Please skip to question 4.
 Please continue with question 3.

Mark [X] only ONE answer.

□ Non-professional (family member, friend, etc.)
□ Professional (accountant, social worker, etc.)
4.

Social Security requires that you have an online account (a username and password) in order to request
personal information on their website. For your recent request, did you create an online account for the first
time or did you use an online account that you created earlier?
Mark [X] only ONE answer.

□ I created an online account for the first time
□ I used an online account I created earlier

 Please continue with question 5.
 Please skip to question 6.

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 using Social Security’s online
service. If a question does not apply to you, please mark Not Applicable.

When you decided to make your request online…
5. Ease of creating an online account to use Social Security’s
online service

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Ease of finding the service on Social Security’s website

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Number of pages you went through before you could start the
request
8. Appearance of the online pages (amount of information, how
the information is arranged, etc.)
Completing the online request…

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10. Helpfulness of the explanations about how to complete your
request

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11. Length of time it took to complete your request online

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Mark [X] ONE answer for every item.

7.

Ease of filling out your request

12. How long did it take you to fill out your request?

Mark [X] only ONE answer.

Excellent

Very
Good

Good

Fair

Poor

Very Poor

Not
Applicable

□ 5 minutes or less
□ Over 5 and up to 10 minutes
□ More than 10 minutes

13. Confirming that they received your request

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14. Explaining how they will process your request

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15. Explaining the security and privacy policies of the website

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Mark [X] ONE answer for every item.

Online explanations from Social Security …

Wait for the information you requested …
16. Length of time it took to receive the information you
requested in the mail
Your overall rating…
17. Overall opinion of the Social Security online service you
used

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Likely

Somewhat
Likely

Not very
Likely

Not at all
Likely

Not
Applicable

18. Recommend Social Security’s website to others

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19. Use Social Security’s website for your future business
(request other information, report a change, etc.)
20. Use a handheld mobile device (smartphone, iPad, etc.) to do
business on Social Security’s website

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Mark [X] ONE answer for every item.

Your likelihood to…

Your need for special accommodations…
21. 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] only ONE answer.

Not
Applicable

Very
Dissatisfied

Somewhat
Dissatisfied

Somewhat
Satisfied

Mark [X] only ONE answer.

Very
Satisfied

□ Yes (Answer question 22 and tell us what special accommodations you need in question 23.)
□ No (Skip to question 23.)

22. How satisfied are you with how well Social Security meets your
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need for special accommodations?
23. Please use this space to provide any comments you may have about Social Security’s online service or to
explain any of your answers.

OMB Control Number 0960-0526; Expiration Date: November 2015

Thank you for taking the time to rate Social Security!
Please send us your “Report Card” in the enclosed postage-paid envelope as soon as possible.

Give Social Security a Report Card...
Please answer the following questions to give us your opinion of the change of address or direct deposit
service you recently used on Social Security’s website.
MARKING INSTRUCTIONS
Correct Marking Example: 
•
•
1.

• Make no stray marks.
• Keep all entries within the boxes.
How did you hear about the change of address or direct deposit service on Social Security’s website?
Mark [X] all that apply.
Use blue or black pen or a number 2 pencil.
Do not use pens with ink that soaks through the paper.

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2.

From Social Security (an employee, their website, written material, etc.)
From a family member or friend
From an Internet search engine or website other than Social Security’s
From online social media (Facebook, Twitter, etc.)
From traditional media (newspaper, magazine, TV or radio, etc.)
From a bank or financial institution
Somewhere else (employer, school, church, etc.)

Did you complete the online request for a change of address or direct deposit by yourself or was someone
else there to help you?
Mark [X] only ONE answer.

□ Completed it by myself
□ Someone else helped me
3.

Who helped you?

 Please skip to question 4.
 Please continue with question 3.

Mark [X] only ONE answer.

□ Non-professional (family member, friend, etc.)
□ Professional (bank employee, attorney, social worker, etc.)
4.

Social Security requires that you have an online account (a username and password) in order to use the
change of address or direct deposit service on their website. To report your change, did you create an online
account for the first time or did you use an online account that you created earlier?
Mark [X] only ONE answer.

□ I created an online account for the first time
□ I used an online account I created earlier

 Please continue with question 5.
 Please skip to question 6.

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 using Social Security’s online
change of address or direct deposit service. If a question does not apply to you, please
mark Not Applicable.

5.

Ease of creating an online account to use Social Security’s
change of address or direct deposit service

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6.

Ease of finding the change of address or direct deposit
service on Social Security’s website

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7.

Number of pages you went through before you could start the
change of address or direct deposit report

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8.

Appearance of the online pages (amount of information, how
the information is arranged, etc.)

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9.

How well Social Security’s website explained what
information you needed to complete your report

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Mark [X] ONE answer for every item.

When you decided to report your change online…

Completing the online report…
10. Ease of answering the questions for your change of address
or direct deposit report
11. Helpfulness of the explanations and examples about how to
complete your report
12. Availability of other help from Social Security to complete
your report
13. Length of time it took to complete your report

14. About how long did it take you to complete your change of address or direct deposit report online?
Mark [X] only ONE answer.

Excellent

Very
Good

Good

Fair

Poor

Very Poor

Not
Applicable

□ 10 minutes or less
□ Over 10 and up to 20 minutes
□ More than 20 minutes

15. Confirming that they received your report

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16. Explaining how they will process your report

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17. Explaining the security and privacy policies of the website

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Mark [X] ONE answer for every item.

Information from Social Security …

Very Poor

Not
Applicable

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Not
Applicable

Poor

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Not at all
Likely

Fair

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Not very
Likely

Good

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Somewhat
Likely

Very
Good

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Very
Likely

Your overall rating…
18. Overall opinion of Social Security’s online change of address
or direct deposit service

Excellent

Mark [X] only ONE answer.

19. Recommend Social Security’s website to others

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20. Use Social Security’s website for your future business
(request information, report a change, etc.)
21. Use a handheld mobile device (smartphone, iPad, etc.) to do
business on Social Security’s website
Your need for special accommodations…

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Mark [X] ONE answer for every item.

Your likelihood to…

22. 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] only ONE answer.
(Answer question 23 and tell us what special accommodations you need in question 24.)

23. How satisfied are you with how well Social Security meets your
□
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□
□
need for special accommodations?
24. Please use this space to provide any comments you may have about Social Security’s online change of
address or direct deposit service or to explain any of your answers.

OMB Control Number 0960-0526; Expiration Date: November 2015

Thank you for taking the time to rate Social Security!
Please send us your “Report Card” in the enclosed postage-paid envelope as soon as possible.

Not
Applicable

Very
Dissatisfied

Somewhat
Dissatisfied

Mark [X] only ONE answer.

Somewhat
Satisfied

(Skip to question 24.)
Very
Satisfied

□ Yes
□ No

□

Internet Report Card Survey - Prenotice Postcard

Dear Social Security Customer:
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
business that you recently completed on our website for yourself or on behalf of another person.
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 online service.
We look forward to hearing your opinions.

Social Security Administration

Internet Report Card Survey – Initial Cover Letter

RE: [Insert type of online business from sample file]

Dear [Insert name from sample file]:
As noted in our recent postcard, Social Security is conducting a survey to find out how well we
served you when you used our website to complete the business shown above for yourself or on
behalf of another person. Please take 5 minutes to fill out the enclosed "Report Card" and return
the form as soon as possible in the postage-paid envelope provided. Please do not put any
information related to 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.
If you have a question about Social Security benefits, please visit our web site
at www.socialsecurity.gov or call our toll-free information line at 1-800-772-1213.
We appreciate your taking time out of your busy schedule to answer our survey.
Sincerely,

Social Security Administration
Enclosures

Internet Report Card Survey – Privacy Act

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.

Internet Report Card Survey – Follow-up Cover Letter

RE: [Insert type of online business from sample file]

Dear [Insert name from sample file]:
About a week ago we sent you a survey form, “Give Social Security a Report Card,” to find out
how well we served you when you used our website to complete the business shown above for
yourself or on behalf of another person. We haven’t yet heard from you and it’s important that
we gather opinions from as many people as possible. If you have already 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 had time to fill out and return your survey, please take a few
minutes right now to do that. The form is short and takes less than 5 minutes to complete. In
case you misplaced the survey, we have enclosed another copy along with a postage-paid return
envelope. Please do not put any information related to 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.
If you have a question about Social Security benefits, please visit our web site
at www.socialsecurity.gov or call our toll-free information line at 1-800-772-1213.
We would appreciate receiving your completed survey as soon as possible.
Sincerely,

Social Security Administration
Enclosures