Individuals and Households

A

OMB Control Number: 0584-0578
Expiration Date: xx/xxxx

PPENDIX B

Public reporting burden for this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-0578). Do not return the completed form to this address.

COMMUNITY PARTNER INTERVIEW DEMONSTRATION PROJECT CLIENT SATISFACTION SURVEY - ENGLISH

Instructions: The United States Department of Agriculture (USDA), Food and Nutrition Service oversees [Insert State SNAP program name]. The USDA would like to learn more about your experience applying for benefits at [Insert Community Agency’s name]. The survey includes questions about your experience applying for benefits. Your answers will help us improve our service. Your answers will be kept private and will not impact your eligibility for the program.

1. Why did you choose this location?

1. You didn’t know there was another way to apply

2. You go there for other services

3. You feel comfortable going there

4. It is conveniently located

5. It has convenient hours of operation

6. You don’t have to wait a long time there

7. The people who work there are friendly

8. The people who work there speak your language

9. Someone referred you there

2. How long did you have to wait?

1. Less than 15 minutes

2. Between 15 and 30 minutes

3. More than 30 minutes but less than an hour

4. More than an hour

5. Don’t know

3. Thinking about your most recent experience applying for [Insert State SNAP program name], how did it compare to your previous experience? Was it easier to apply this time, harder or about the same?

1. Easier to apply this time

2. Harder to apply this time

3. About the same

4. Don’t know

5. This is the first time I have applied for [Insert State SNAP program name]

4. Did you feel like this location offered you enough privacy?

1. Yes

2. No

3. Don’t know

5. Overall, the staff I met was very knowledgeable about the [Insert State SNAP program name] and the procedures for applying for benefits. Do you:

1. Strongly agree

2. Agree

3. Disagree

4. Strongly disagree

5. Don’t know

6. Thinking again about your interview for [Insert State SNAP program name], how satisfied were you with the overall interview process, and having the interviewer explain the verification procedures in a way that was clear to you? Were you:

1. Very Satisfied

2. Satisfied

3. Dissatisfied

4. Very Dissatisfied

5. Don’t know