Stage 1 First Contact Letter Survey

BOND Stage 1 First Contact Letter Survey
1. CONTACT INFORMATION (To be completed by interviewer prior to call.)
a. Participant First Name ____________________
b. Participant Last Name ____________________
c. Telephone Number ____________________
d. Participant BOND ID ____________________
e. Interviewer Name ____________________
f. Interview Date: ____________________
Introduction
2. Hello, may I speak to [Participant Name]? (I am calling on behalf of the Social
Security Administration. I am with [TBD] and we are conducting a 3-minute
survey for the Social Security Administration. The survey is for people who
recently received a letter about the Benefit Offset National Demonstration project,
also known as BOND. We will not talk about any personal information.)

Speaking >>>> The Privacy Act requires us to notify you that we are
authorized to collect this information by section 702 of the Social Security Act.
You do not have to provide the information requested. However, the information
you provide will help us evaluate and improve the Benefit Offset National
Demonstration project. Your individual answers will be kept completely
confidential and will not affect your future benefits in any way. We estimate that it
will take about 3 minutes to complete this survey. This includes the time it will
take to listen to the questions and give your responses. If at the end of this
survey you would like to submit comments on the time estimate for this survey,
please let me know. (NOTE TO INTERVIEWER: If at the end of the survey
respondent wants to comment on time estimate, please read Paperwork
Reduction Act Statement).

New person comes to phone >>>> READ ONLY IF NOT READ AT S1. I
am calling on behalf of the Social Security Administration. I am with [TBD] and
we are conducting a 3-minute survey for the Social Security Administration. The
survey is for people who recently received a letter about the Benefit Offset
National Demonstration project, also known as BOND. We will not talk about any
personal information.

Not available/bad time [Arrange callback]

No longer lives here >>>> Skip to End Page: Survey Submitted

Refused >>>> Skip to End Page: Survey Submitted
2a. READ ONLY IF NOT READ AT S1. I am calling on behalf of the Social
Security Administration. I am with [TBD] and we are conducting a 3-minute
survey for the Social Security Administration. The survey is for people who
recently received a letter about the Benefit Offset National Demonstration project,
also known as BOND. We will not talk about any personal information.
 Paragraph 2 OR 2a was read to participant

2b. The Privacy Act requires us to notify you that we are authorized to collect this
information by section 702 of the Social Security Act. You do not have to provide
the information requested. However, the information you provide will help us
evaluate and improve the Benefit Offset National Demonstration project. Your
individual answers will be kept completely confidential and will not affect your
future benefits in any way. We estimate that it will take about 3 minutes to
complete this survey. This includes the time it will take to listen to the questions
and give your responses. If at the end of this survey you would like to submit
comments on the time estimate for this survey, please let me know. (NOTE TO
INTERVIEWER: If at the end of the survey respondent wants to comment on
time estimate, please read Paperwork Reduction Act Statement).
 Paragraph 2b was read to participant
Survey Questions
3. Did you receive a letter from the Social Security Administration about the
Benefit Offset National Demonstration, or BOND?

Yes

No >>>> Would you like to speak with someone about the BOND project?

Not sure >>>> Would you like to speak with someone about the BOND
project?
4. What information was covered in the letter? [DO NOT READ] [Select all that
apply]
 I did not read it
 I don't remember
 It's a new program
 I can work and keep more of my benefits
 Other (specify) ___________________________________
5. Have you called the BOND toll-free number?

Yes

No
6. Have you visited the BOND website?

Yes

No
7. Do you plan to participate in the BOND project?

Yes >>>> Would you like to speak with someone about the BOND project?
[Provide toll free number and end call]

No

I'm not sure
8. Please explain why are you are not interested in the BOND project.
______________________________________________________________
______________________________________________________________

______________________________________________________________
Go To END
9. Would you like to speak with someone about the BOND project?

Yes [Provide toll free number and end call]

No [Go To END]
END
Thank you for talking to me today. What you've told us is very important, and
we'd like to thank you for your time and assistance. If you have any other
questions about the BOND project later on, you can call us toll-free at 1-8777BOND09 (1-877-726-6309).
Thank you.
NOTE TO INTERVIEWER:
IF THE RESPONDENT DOES NOT WANT TO COMMENT ON THE TIME
ESTIMATE, YOU DO NOT NEED TO READ THE STATEMENT BELOW. IF
THE RESPONDENT DOES WANT TO COMMENT, PLEASE READ THE
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. The OMB number for this information
collection is 0960-XXXX. We estimated that it would take about 3 minutes to
participate in this survey. Send only comments on our time estimate to: SSA,
6401 Security Blvd., Baltimore, MD 21235-6401.