2014 TTW EN Beneficiary Satisfaction Survey

OMB No. 0960-0526

TTW Beneficiary Survey (English)

1. The name of your current or previous Employment Network is/was…

__ [INSERT EN NAME]  Skip to section “About your Employment Network”

__ A Different Employment Network:_________ => Go to Q 2

__ I currently do not have Employment Network => Go to Q 2

2. Please look at the list below and select reason(s) why you are no longer with this Employment Network. (Please check all that apply)

__ Unable to work because of health or disability reasons

__ Dissatisfied with my Employment Network

__ Employment Network terminated their services or unassigned my Ticket

__ Do not want or need employment

__ Do not want to lose my SSI and/ or SSDI benefits

__ Do not want to lose my Medicaid or Medicare benefits

__ Other (Please specify):___________________

Please GO TO next section “About Employment Network”

ABOUT EMPLOYMENT NETWORK

<INSERT NAME OF EMPLOYMENT NETWORK>

Thinking about Employment Network [INSERT EN NAME], please rate your level of satisfaction with the following aspects of this Employment Network. If you are a representative payee answering on behalf of a beneficiary, please choose the level of satisfaction you believe the beneficiary had/has with the following aspects of this Employment Network.

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

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

__ 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. 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

9. My satisfaction with my Employment Network overall.

__ Completely Satisfied

__ Somewhat Satisfied

__ Neither Satisfied or Dissatisfied

__ Somewhat Dissatisfied

__ Completely Dissatisfied

10. How many Employment Networks did you contact for information prior to assigning your

ticket to your current Employment Network?

__ 0

__ 1

__ 2 to 3

__ 4 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

__ Recommended by another person who receives disability benefits (SSI or SSDI)

__ 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 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?

(Please check all that apply. It is okay to check boxes in each column, or not check any boxes)

	Services you and your EN agreed were needed	Services you actually received	Services you expect to receive in the future
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 currently employed?

__ Yes, Full-time (30 hours a week or more)  Skip to Q 19

__ Yes, Part-time (less than 30 hours a week)  Go to Q 15

__ No, not currently employed  Skip to Q 22

15. Why are you currently employed part-time? (Please choose all that apply)

__ Personal choice

__ Only available form of employment

__ Health or disability considerations

__ Intended as initial entry/ re-entry to work force

__ Do not want to lose my SSI and/or SSDI benefits

__ Do not want to lose my Medicaid or Medicare benefits

__ Other (Please specify):___________

16. Please answer the following questions pertaining to full-time employment.

(Please check either yes or no for each item)

	Yes	No
Have you ever been employed full-time?	□	□
Would you be interested in full-time employment?	□	□

17. Have you worked full-time since you assigned your Ticket?

__ Yes

__ No  Skip to Q 19

18. If you were employed full-time after Ticket assignment, for what reasons are you no longer employed full-time? (Please choose all that apply)

__ Left for personal reasons

__ Health or disability considerations

__ Working multiple part-time jobs

__ Lack of reliable transportation

__ Workplace issues

__ Did not want to lose my SSI and/or SSDI benefits

__ Did not want to lose my Medicaid or Medicare benefits

__ Laid off by employer

__ Other (Please specify): ____________________

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

__ 1-2 years ago

__ 3 or more years ago

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

__ Yes

__ No

For classification purposes, please provide a response to the following question.

20. 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

21. How much do you agree or disagree with the following statement?

It is my goal to substitute or reduce my need for disability cash benefits with earnings from work.

__ Strongly Agree

__ Somewhat Agree

__ Neither Agree or Disagree

__ Somewhat Disagree

__ Strongly Disagree

COMMENTS

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

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 12 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.

Postcard Inviting Beneficiary to Participate (English)

Back of post card:

Dear <insert full name>:

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, 12-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 12 minutes to complete.

Please complete this survey at your earliest convenience.

We want to thank you in advance for sharing your opinions.

Ticket to Work National Evaluation

C/O EurekaFacts National Survey Center

51 Monroe Street, PE-10

Rockville, MD 20850

<insert name>

<insert address>

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

Front of post card:

Initial Letter Mailed out to Beneficiaries (English)

<insert date>

<insert name>
<insert address>

Dear <insert name>,

The Social Security Administration has asked EurekaFacts to contact you 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, <insert Employment Network>, are being asked to complete a 12-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 a postage-paid 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 [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 <insert date>. The survey will take you approximately 12 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 or email to [email protected].

Sincerely,

EurekaFacts, LLC, on behalf of the Social Security Administration

Survey Questionnaire EN Cover Letter (English)

CONSUMER SATISFACTION SURVEY

YOUR HELP IS VERY IMPORTANT! This survey has been mailed to Social Security Administration beneficiaries. 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. 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/was <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 (OMB) control number. The OMB control number is 0960-0526. We estimate that it will take about 12 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, PE-10

Rockville, Maryland, 20850

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

_____________________________________________________________________________________________

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