TTW EN Beneficiary Satisfaction Survey

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 knowledge of staff members I interacted with at my Employment Network.
__ Completely Satisfied
__ Somewhat Satisfied
__ Neither Satisfied or Dissatisfied
__ Somewhat Dissatisfied
__ Completely Dissatisfied
3. The respectfulness of the staff at my Employment Network.
__ Completely Satisfied
__ Somewhat Satisfied
__ Neither Satisfied or Dissatisfied
__ Somewhat Dissatisfied
__ Completely Dissatisfied
4. The ability of my Employment Network to help me understand the type of jobs available in my
community.
__ Completely Satisfied
__ Somewhat Satisfied
__ Neither Satisfied or Dissatisfied
__ Somewhat Dissatisfied
__ Completely Dissatisfied
5. The information given to me by my Employment Network about other agencies in my community
that was useful in helping me reach my employment goal.
__ Completely Satisfied
__ Somewhat Satisfied
__ Neither Satisfied or Dissatisfied
__ Somewhat Dissatisfied
__ Completely Dissatisfied

6. The usefulness of the services provided by my Employment Network in helping me meet my
employment goals.
__ Completely Satisfied
__ Somewhat Satisfied
__ Neither Satisfied or Dissatisfied
__ Somewhat Dissatisfied
__ Completely Dissatisfied
7. The usefulness of the services provided by my Employment Network in helping me meet my
financial goals.
__ Completely Satisfied
__ Somewhat Satisfied
__ Neither Satisfied or Dissatisfied
__ Somewhat Dissatisfied
__ Completely Dissatisfied
8. My satisfaction with my Employment Network overall.
__ Completely Satisfied
__ Somewhat Satisfied
__ Neither Satisfied or Dissatisfied
__ Somewhat Dissatisfied
__ Completely Dissatisfied
9. Before assigning your ticket to this Employment Network, did you consider assigning your ticket
to a State Vocational Rehabilitation (VR) agency?
__ Yes
__ No
__ Don’t know
10. Before assigning your ticket to this Employment Network, did you consider assigning your ticket
to another Employment Network?
__ Yes
__ No  Go to Q11
__ Don’t know  Go to Q11
10a. How many other Employment Networks did you contact for information prior to assigning your
ticket to your current Employment Network?

__ 1 or 2
__ 3 to 5
__ 6 or more

11. Why did you assign your ticket to your current Employment Network? (Please check all that
apply)
__ The only provider nearby/closest provider

__ Most willing to provide the services I wanted
__ Recommended by a caseworker or other provider
__ Staff were responsive/courteous/knowledgeable
__ They focus on assisting people with my type of disability
__ Only provider willing to accept my ticket
__ Some other reason (Please specify) _________________________________________
12. After you assigned your ticket, please indicate a) which services you and your Employment
Network agreed were needed, b) which services you actually received from your Employment
Network, and c) which services you expect to receive from your Employment Network in the
future?

Services you and
your EN agreed
were needed

Services
you received from your
EN

Services you
expect to receive in
the future

(check all that apply)

(check all that apply)

(check all that apply)

Career planning

□

□

□

Help finding a job

□

□

□

Job coaching/Training

□

□

□

Ongoing support to keep a job

□

□

□

Help obtaining services from
other organizations

□

□

□

Benefits counseling or referral to
benefits counseling

□

□

□

13. 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

□

□

Respectfulness of staff members

□

□

Quality of Services

□

□

Help provided during job search

□

□

Amount of time waiting for follow-up services

□

□

Information provided about local jobs

□

□

Support received from staff

□

□

Information in accessible formats (e.g., Braille,
online, print, another language)

□

□

Hours of operation

□

□

Responsiveness of staff in returning phone calls and
emails

□

□

ABOUT YOUR JOB
14. Are you employed on a full-time or part-time basis?
__ Yes
__ No  Go to Q 20
15. When did you begin working at your current job?
__ Within the last three months
__ 3 - 6 months ago
__ 7 - 9 months ago
__ 10 - 12 months ago
__ More than 12 months ago
16. About how many hours a week do you normally work at your current job? _____ hours per week
17. Did your Employment Network provide services that helped you get your current job?
__ Yes
__ No
18. 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
19. 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
20. How much do you agree or disagree with the following statement?
It is my goal to reduce or eliminate my reliance on disability benefits with earnings from work.
__ Strongly Agree
__ Somewhat Agree
__ Neither Agree nor Disagree
__ Somewhat Disagree
__ Strongly Disagree

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

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.

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 .

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
51 Monroe Street, Plaza East 10
Rockville, Maryland, 20850
If you completed the survey online, you do not need to send the paper questionnaire.
_______________________________________________________________________________________________________

Dear :
EurekaFacts is conducting an evaluation of the Ticket to Work Program on behalf of the Social
Security Administration. We are asking for you to help us learn about your experience in the
Ticket to Work program by completing a short, 10-minute survey. You were selected because you
have used your ticket with an Employment Network under the Ticket to Work program and will be
able to provide your opinions. If you are a representative payee answering on behalf of a
beneficiary, please fill out the survey to the best of your ability to reflect the opinions of the
beneficiary. To protect the confidentiality of your responses, the Employment Network’s staff will
not see your answers. To participate in this study,

Go to the website: http://www.eurekafacts.com/ttw.html
and enter your unique ID number [abc123]
The survey will take you approximately 10 minutes to complete.
Please complete this survey by [date].

We want thank you in advance for sharing your opinions.

Ticket to Work National Evaluation
C/O EurekaFacts National Survey Center
51 Monroe Street, Plaza East 10
Rockville, MD 20850

Please go to the website: http://www.eurekafacts.com/ttw.html and enter your
unique ID number [abc123]

Dear ,
EurekaFacts is contacting you on behalf of the Social Security Administration because you are a Social
Security beneficiary who has participated in the Ticket to Work program. We are asking for you to help
us learn about your experience with the program. Social Security beneficiaries who have used their
tickets with your Employment Network, , are being asked to complete a
10-minute survey.
The person or organization to whom this letter is addressed should be the person who completes the
survey. If this person or organization is a representative payee answering on behalf of a beneficiary,
they should fill out the survey to the best of their ability to reflect the opinions of the beneficiary.
We would like to make it easy for you to participate in this study. You may complete the survey either
on the Internet or by mail using the paper survey form included with this letter. You do not need to do
both. If you complete the paper survey, we have provided an envelope in which you may return the
paper survey. To complete the survey online please do the following:
Go to the website: www.eurekafacts.com/ttw.html
and enter your unique ID number [abc123]
The Employment Network’s staff will not see your answers and your name will not appear on the
survey. Social Security will use all responses to improve the program.
Please complete this survey by [date]. The survey will take you approximately 10 minutes to complete.
Thank you in advance for your help.
EurekaFacts is conducting this survey on behalf of Social Security and the Ticket to Work program. If you
have any questions about this survey, you may contact EurekaFacts at 1-855-403-4800.
Sincerely,

EurekaFacts – Ticket to Work