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pdfPRENOTICE POSTCARD - ENGLISH
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
INITIAL COVER LETTER - ENGLISH
Dear Social Security Applicant:
As noted in our recent postcard, Social Security is conducting a survey to get your opinion of the
service you received when you requested a hearing on your application for Social Security
disability benefits. We would like to hear from you even if you did not attend a hearing with a
judge.
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 [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.
Thank you for sharing your opinions with us.
Sincerely,
Social Security Administration
FOLLOW-UP POSTCARD - ENGLISH
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
FOLLOW-UP COVER LETTER - ENGLISH
Dear Social Security Applicant:
About a month ago we sent you a brief survey asking about the service you received when you
requested a hearing on your 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. We
would like you to answer our survey even if you did not attend a hearing with a judge.
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 - ENGLISH
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.
PRENOTICE POSTCARD - SPANISH
Estimado(a) Solicitante del Seguro Social:
La Administración del Seguro Social cree que una de las mejores maneras de saber si el público está satisfecho
con nuestro servicio es a través de encuestas. Es por eso que muy pronto le estaremos pidiendo su opinión
sobre el servicio que recibió durante su reciente asunto con el Seguro Social.
En unos días, usted recibirá un corto cuestionario por correo de Synovate, quien está llevando a cabo esta
encuesta por parte del Seguro Social. Cuando lo reciba, esperamos que tome el tiempo para contestar nuestras
preguntas y decirnos lo que piensa de nuestro servicio.
Esperamos escuchar sus opiniones.
Administración del Seguro Social
INITIAL COVER LETTER – SPANISH
Estimado(a) Solicitante del Seguro Social:
Según le indiqué en la tarjeta postal que le envié recientemente, el Seguro Social está llevando a cabo una
encuesta para obtener su opinión sobre el servicio que recibió cuando solicitó una audiencia de su solicitud para
beneficios de Seguro Social por incapacidad. Nos gustaría oír de usted aún si no asistió a una audiencia con un
juez.
La encuesta es corta y le debe tomar sólo 5 minutos en llenarla. Por favor tome unos minutos ahora para
contestar las preguntas y devuelva el formulario lo antes posible en el sobre franqueado provisto. Aunque no
está requerido a responder, sus opiniones son muy importantes para nosotros y nos gustaría oír de tantas
personas como sea posible. Por favor no incluya en el sobre con la encuesta, ninguna información
relacionada a sus asuntos con el Seguro Social.
Por favor, siéntase seguro de que Synovate, quien está llevando a cabo esta encuesta por nosotros, proveerá sus
respuestas solamente a el personal aquí en el Seguro Social y no las usará para ningún otro propósito. El
Seguro Social presentará los resultados de la encuesta con un resumen de las respuestas de todas las personas
que tomen la misma; no presentaremos informes individuales de las respuestas. Su participación en esta
encuesta no afectará su derecho a beneficios o cualquier otro asunto que tenga con el Seguro Social.
Si tiene alguna pregunta sobre su petición para una audiencia o los beneficios, por favor llame al número gratis
del Seguro Social para información al 1-800-772-1213 o visite nuestro sitio de Internet
en www.segurosocial.gov.
Gracias por compartir sus opiniones con nosotros.
Sinceramente,
Administración del Seguro Social
Anexos
FOLLOW UP POSTCARD – SPANISH
Estimado(a) Solicitante del Seguro Social:
Alrededor de dos semanas atrás, le enviamos una encuesta pidiendo su opinión sobre el servicio que recibió
durante su reciente asunto con el Seguro Social.
•
•
•
Si ya envió la encuesta completada por correo, gracias por su pronta respuesta.
Si no, por favor tome 5 minutos ahora para llenar y devolver la encuesta en el sobre franqueado
provisto.
Si ya no la tiene, no tiene que hacer nada. Synovate, quien está llevando a cabo la encuesta por
nosotros, le enviará otro formulario por correo pronto.
Muchas gracias por su ayuda con esta encuesta.
Administración del Seguro Social
FOLLOW-UP COVER LETTER – SPANISH
Estimado(a) Solicitante del Seguro Social:
Alrededor de un mes atrás, le enviamos una breve encuesta pidiéndole su opinión sobre el
servicio que recibió cuando solicitó una audiencia de su solicitud para beneficios de Seguro
Social por incapacidad. No hemos oído de usted y es muy importante que reunamos opiniones
de tantas personas como sea posible. Nos gustaría que respondiera a nuestra encuesta aún si no
asistió a una audiencia con un juez.
Si envió la encuesta completada recientemente, favor de ignorar esta carta. Sinceramente
apreciamos su ayuda y estamos ansiosos de recibir su respuesta. Sin embargo, si todavía no la ha
devuelto, por favor tome unos 5 minutos ahora mismo para llenarla y enviárnosla. Para su
conveniencia, hemos incluido otra copia junto con un sobre franqueado. Por favor no incluya
en el sobre con la encuesta, ninguna información relacionada a sus asuntos con el Seguro
Social.
Por favor, siéntase seguro de que Synovate, quien está llevando a cabo esta encuesta por
nosotros, proveerá sus respuestas solamente a el personal aquí en el Seguro Social y no las usará
para ningún otro propósito. El Seguro Social presentará los resultados de la encuesta con un
resumen de las respuestas de todas las personas que tomen la misma; no presentaremos informes
individuales de las respuestas. Su participación en esta encuesta no afectará su derecho a
beneficios o cualquier otro asunto que usted tenga con el Seguro Social.
Si tiene alguna pregunta sobre su petición para una audiencia o los beneficios, por favor llame al
número gratis del Seguro Social para información al 1-800-772-1213 o visite nuestro sitio de
Internet en www.segurosocial.gov.
Le agradeceríamos si recibimos su encuesta llena lo antes posible.
Sinceramente,
Administración del Seguro Social
Anexos
PRIVACY ACT - SPANISH
DECLARACIÓN DE LA LEY DE CONFIDENCIALIDAD
La Administración del Seguro Social tiene la autorización de colectar la información para esta
encuesta bajo la orden ejecutiva 12862, «Setting Customer Service Standards» (en español,
«Estableciendo el nivel de la calidad del servicio al consumidor»). Sus respuestas a estas
preguntas son completamente voluntarias. La información que nos provea se usará para
ayudarnos a mejorar el servicio que le proveemos. Sus respuestas no serán divulgadas a otras
agencias gubernamentales o privadas.
LEY PARA LA REDUCCIÓN DE TRÁMITES
Esta recopilación de información cumple con los requisitos de 44 U.S.C. &3507, según
enmendada por la sección 2 de La Ley para la Reducción de Trámites del 1995. No es requisito
que usted conteste estas preguntas a menos que el formulario de la encuesta muestre un número
de control válido de la Oficina de Administración y Presupuesto. Calculamos que le tomará
5 minutos para llenar esta encuesta. Esto incluye el tiempo que le tomará leer las instrucciones,
recaudar los datos y contestar las preguntas. Puede enviar comentarios sobre nuestra estimación
del tiempo mencionado anteriormente a: Social Security Administration, 6401 Security Blvd.,
Baltimore, MD 21235-6401. Envíe sólo los comentarios sobre nuestra estimación de tiempo a
esta dirección, no el formulario lleno.
FY 18 HPRC AWARD SURVEY - ENGLISH
Hearings Process Report Card Survey
Please complete this questionnaire to give us your opinion of the service you received when you
requested a hearing on your application for disability benefits.
MARKING INSTRUCTIONS
Correct Marking Example:
• Use blue or black pen or a number 2 pencil.
• Make no stray marks.
• Do not use pens with ink that soaks through the • Keep all entries within the boxes.
paper.
1. How was your request for a hearing completed? Was it completed:
(If you used more than one way, please check the main way.) Mark [X] only ONE.
In person with a Social Security employee Go to question 4.
Over the telephone with a Social Security employee Go to question 4.
Through the mail Go to question 4.
On Social Security’s Internet website (www.socialsecurity.gov) Go to question 2.
2. After you completed your disability application online, did Social Security contact you for additional
information related to your application? Mark [X] only ONE.
Yes. Go to question 3
No. Go to question 4.
3. What was the additional information that Social Security needed? Was the information related to your:
Mark [X] all that apply.
Identification (Name, SSN, Date of Birth, Address, Phone Number)
Date on the Decision Notice
Information about your Representative (Name, Address, Phone Number)
Medical Treatment Records (doctors, hospitals, test, medication list)
Medical Release Forms
Current Work Information
Something else. Please Explain:__________________________________________
Not
Applicable
Very Poor
Poor
Fair
Mark [X] ONE answer for every item.
Good
Excellent
If a question does not apply to you, please
mark Not Applicable.
Very Good
Please use the scale shown to rate the following aspects of your hearing experience.
When you decided to request a hearing…
4.
Ease of finding information about how to file
your hearing request
5.
Quality of information you got from Social
Security explaining the hearing process
While you were waiting for your hearing to be held…
6.
Ease of contacting Social Security about your
hearing request
7.
Helpfulness of the information Social Security
gave you about your hearing request
How your hearing was held…
8.
Did you have a hearing with a judge face-to-face or by video conference?
Mark only ONE answer.
Hearing was face-to-face with a judge.
Please continue with question 9
Hearing was by video conference with a judge.
Please continue with question 9
No hearing was held with a judge.
Please continue with question 16
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 hearing experience.
Mark [X] ONE answer for every item
10. How well the judge explained what would
happen at your hearing
11. How prepared the judge was to talk about the
facts of your case
12. Opportunity the judge gave you or your
representative to present the facts of your case
13. Courtesy of the judge
14. Length of time from the date you first
requested your hearing until it was held
15. Length of time from the date your hearing was
held until you received the decision
16. Overall length of time from the date you first
requested your hearing until you received the
decision
17. How well the notice explained the decision
18. How well the notice explained the amount of
your benefits and when they would start
19. Helpfulness of the staff
20. Overall experience with the hearing on your
disability application
21. Overall opinion of Social Security’s service
When your hearing was held…
9.
Location of the office where your hearing was
held
Waiting for the hearing and decision…
Notice of Social Security’s decision …
Your overall experience with Social Security…
A little more about you…
22. Now we would like to ask you about doing business on the Internet. First, do you currently use the
Internet? Mark [X] ONE answer.
Yes
No SKIP to Question 26.
23. How do you access the Internet? Do you use: Mark [X] ONE answer.
Only a personal computer or laptop computer
Only a wireless handheld device (smartphone, tablet, etc.)
Both a PC and a wireless handheld device
24. We offer a service called “my Social Security” where people can create a secure online account with a
user name and password to conduct various types of business. For example, you can check the status of
your application. Have you already created your “my Social Security” account? Mark [X] ONE answer.
Yes GO to Question 25.
No SKIP to Question 26.
25. How have you used your “my Social Security” account? Mark [X] all that apply.
Viewed my Social Security Statement
Changed my address/telephone number
Added or changed my direct deposit information
Got a proof of income letter to verify the benefits I receive
Checked the status of my disability claim
Requested a replacement Social Security Card
I have not used my account yet
26. Do you own a cell phone? Mark [X] ONE answer.
Yes GO to Question 27
No
End Survey.
27. Do you use a cell phone to send and receive text messages? Mark [X] ONE answer.
Yes
No
OMB Control Number 0960-0526, Expiration Date: TBD
FY 18 HPRC DENIAL SURVEY - ENGLISH
Hearings Process Report Card Survey
Please complete this questionnaire to give us your opinion of the service you received when you
requested a hearing on your application for disability benefits.
MARKING INSTRUCTIONS
Correct Marking Example:
• Use blue or black pen or a number 2 pencil.
• Use blue or black pen or a number 2 pencil.
• Do not use pens with ink that soaks through the • Do not use pens with ink that soaks through the
paper.
paper.
1. How was your request for a hearing completed? Was it completed:
(If you used more than one way, please check the main way.) Mark [X] only ONE.
In person with a Social Security employee Go to question 4.
Over the telephone with a Social Security employee Go to question 4.
Through the mail Go to question 4.
On Social Security’s Internet website (www.socialsecurity.gov) Go to question 2.
2. After you completed your disability application online, did Social Security contact you for additional
information related to your application? Mark [X] only ONE.
Yes. Go to question 3
No. Go to question 4.
3. What was the additional information that Social Security needed? Was the information related to your:
Mark [X] all that apply.
Identification (Name, SSN, Date of Birth, Address, Phone Number)
Date on the Decision Notice
Information about your Representative (Name, Address, Phone Number)
Medical Treatment Records (doctors, hospitals, test, medication list)
Medical Release Forms
Current Work Information
Something else. Please Explain:__________________________________________
Not
Applicable
Very Poor
Poor
Fair
Mark [X] ONE answer for every item.
Good
Excellent
If a question does not apply to you, please
mark Not Applicable.
Very Good
Please use the scale shown to rate the following aspects of your hearing experience.
When you decided to request a hearing…
4.
Ease of finding information about how to file
your hearing request
5.
Quality of information you got from Social
Security explaining the hearing process
While you were waiting for your hearing to be held…
6.
Ease of contacting Social Security about your
hearing request
7.
Helpfulness of the information Social Security
gave you about your hearing request
How your hearing was held…
8.
Did you have a hearing with a judge face-to-face or by video conference?
Mark only ONE answer.
Hearing was face-to-face with a judge.
Please continue with question 9
Hearing was by video conference with a judge.
Please continue with question 9
No hearing was held with a judge.
Please continue with question 16
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 hearing experience.
Mark [X] ONE answer for every item
10. How well the judge explained what would
happen at your hearing
11. How prepared the judge was to talk about the
facts of your case
12. Opportunity the judge gave you or your
representative to present the facts of your case
13. Courtesy of the judge
14. Length of time from the date you first
requested your hearing until it was held
15. Length of time from the date your hearing was
held until you received the decision
16. Overall length of time from the date you first
requested your hearing until you received the
decision
17. How well the notice explained the decision on
your hearing
18. How well the notice explained what to do if
you disagreed with the decision
19. Helpfulness of the staff
20. Overall experience with the hearing on your
disability application
21. Overall opinion of Social Security’s service
When your hearing was held…
9.
Location of the office where your hearing was
held
Waiting for the hearing and decision…
Notice of Social Security’s decision on your hearing…
Your overall experience with Social Security…
A little more about you…
22. Now we would like to ask you about doing business on the Internet. First, do you currently use the
Internet? Mark [X] ONE answer.
Yes
No SKIP to Question 26.
23. How do you access the Internet? Do you use: Mark [X] ONE answer.
Only a personal computer or laptop computer
Only a wireless handheld device (smartphone, tablet, etc.)
Both a PC and a wireless handheld device
24. We offer a service called “my Social Security” where people can create a secure online account with a
user name and password to conduct various types of business. For example, you can check the status of
your application. Have you already created your “my Social Security” account? Mark [X] ONE answer.
Yes GO to Question 25.
No SKIP to Question 26.
25. How have you used your “my Social Security” account? Mark [X] all that apply.
Viewed my Social Security Statement
Changed my address/telephone number
Added or changed my direct deposit information
Got a proof of income letter to verify the benefits I receive
Checked the status of my disability claim
Requested a replacement Social Security Card
I have not used my account yet
26. Do you own a cell phone? Mark [X] ONE answer.
Yes GO to Question 27
No
End Survey.
27. Do you use a cell phone to send and receive text messages? Mark [X] ONE answer.
Yes
No
OMB Control Number 0960-0526, Expiration Date: TBD
| File Type | application/pdf |
| File Title | Dear [INSERT NAME]: |
| Author | DPICKET |
| File Modified | 2017-09-05 |
| File Created | 2017-09-05 |