Attachment B - Respondent Correspondence

ATTACHMENT B
RESPONDENT CORRESPONDENCE

ATTACHMENT B1
ADVANCE LETTER

SOCIAL SECURITY
Para información e instrucciones en español, llame XXX-XXX-XXXX por favor.
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
We need your help with an important study sponsored by the Social Security Administration
(SSA), the National Beneficiary Survey (NBS). The NBS asks about your health, work, and
services you may have gotten in the past year. The goal is to make programs better for people
who get Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI).
Taking part in the NBS is your choice. We will not share your answers in any way that reveals
who you are. We will not use your answers to make changes to your benefits. We will use your
information only for research.
We hired a company called Mathematica Policy Research to help us with this study. A
representative from the company will call to speak with you in about a week. Mathematica will
send you a $20 gift card as a thank you after you finish the survey.
Your participation is very important to us. If you want to set up a time to talk or need help to take
the survey, please call Mathematica at 877-XXX-XXXX (toll-free) or send an email to
[email protected]. If you would like to talk to the person leading the project at
SSA, [FILL NAME], please call Mathematica and they will forward your call to [him/her].
A pamphlet about the study is included with this letter. You can also read about the study by
going to https://www.ssa.gov/disabilityresearch/nbs_participants.html.
We look forward to talking with you. Thank you for your help.
Sincerely,

David A. Weaver
Associate Commissioner
Office of Research, Demonstration, and
Employment Support
Office of Retirement and Disability Policy

Privacy Act Statement
Collection and Use of Personal Information

Public Law 106-170 Section 101 (1)(d)(4)(C)(i), allows us to collect this information. We will
use your answers to learn more about disability beneficiaries, how well our programs are
working, and design new programs. The information will solely be used for research purposes to
improve SSA's programs and policies.
Participation is voluntary and participating or not participating will not affect your benefits.
We use the information you supply primarily for the purposes stated above. However, we may
use it for the administration and integrity of our programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but
are not limited to the following:
1. To comply with Federal laws requiring the release of information from Social Security
records (e.g. to the Government Accountability Office and Department of Veterans
Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs, including responding to
questions from Congress.
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0058, Master Files of Social Security
Number (SSN) Holders and SSN Applications. Additional information about this and other
system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.

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 for this collection is 0960-XXXX; expiration date XX/XX/XXXX. We estimate that it
will take about 60 minutes to read the instructions, and answer the questions. You may send
comments on our time estimate to: Social Security Administration, 6401 Security Blvd,
Baltimore, MD 21235-6401

ATTACHMENT B2
SSA BROCHURE

The National Beneficiary Survey
What is the National Beneficiary Survey?
The National Beneficiary Survey is an important study by the Social Security
Administration (SSA). The study began in 2004 to collect information from people using
Social Security disability programs, including:






The programs and services they use
Their health and wellness
Their goals
Their education and training
Any support they need to work

This year, we are talking to people like you who receive (or used to receive) Social
Security Disability Insurance (DI) or Supplemental Security Income (SSI). We want to
find out how these programs are working for you.
As a thank you, you will receive a $20 gift card after you finish the interview. The $20
gift card does not count as income. Also, since you get it only once, the $20 is not
included in calculating the benefits of SSI recipients.

What have we learned from this survey so far?
SSA uses the information from the survey to understand the challenges people face in
trying to work and live on their own. It also helps us to make our programs better for
people with disabilities.
Here are some of the things we have learned from this survey in the past:






Most people don’t know about Social Security programs that can help them
live more independently or work.
People use many different services to help them live on their own or work
(like special equipment and counseling and occupational therapy, job training
and help finding work).
1 out of 10 people said they are not getting the services that they need.
Even with health problems, many people in Social Security programs want to
work: 4 out of 10 people we talked to in 2010 said they had work goals or saw
themselves working within the next five years.

How long will the interview take?
The interview will take about 60 minutes. We can do the interview at a time that is best
for you. You can complete the interview in more than one phone call.

How did you choose me?
We picked you by chance from a list of people who receive or used to receive Social
Security disability benefits. You represent other people like yourself across the country,
so taking part in this survey is important to its success. Also, because we picked you by
chance, we cannot pick someone else to take your place.

How do I take part?
We have hired a company, Mathematica Policy Research, to do this survey for us. An
interviewer will call you soon. If you want to do the interview now, you can call
Mathematica toll free at <877-XXX-XXXX>. If you cannot do a phone interview, we can
use a telecommunications relay service (TRS), video relay (VRS), or instant messaging
service (such as AIM). We can also do the interview in Spanish or use an interpreter if
you speak another language. In most cases, we can send an interviewer to your home
to speak to you in person. Your participation is important to us.
You do not have to do the interview at all. If you do the survey, you can skip any
question you do not want to answer.
Note: The interviewer will never ask for your social security number.

Who can I contact with questions?
If you have questions, or need help, you can call Mathematica toll free at <877-XXXXXXX>. You can send questions or updated contact information to
[email protected].
You can also write to Mathematica at:
National Beneficiary Survey
Mathematica Policy Research
1100 1st Street, NE, 12th Floor, Washington, DC 20002-4221
Website: www.mathematica-mpr.com
[twitter logo] MathPolResearch
[facebook logo] Facebook

For more information about the survey, please visit our website:
http://www.ssa.gov/disabilityresearch/nbs.html

ATTACHMENT B3
REMINDER LETTERS

SOCIAL SECURITY
Para información e instrucciones en español, llame XXX-XXX-XXXX por favor.
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
Recently, we sent you a letter about an important study sponsored by the Social Security
Administration, the National Beneficiary Survey (NBS). This study will tell us about people
who use Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI).
Sharing your experiences will help us make our programs better.
Taking part in the NBS is your choice. We will not share your answers in any way that reveals
who you are. We will not use your answers to make changes to your benefits. We will use your
information only for research.
If you already took part in the study, thank you. If you have not yet taken part, please do so
today. We hired a company called Mathematica Policy Research to conduct this study for us.
You can call the company for free at 877-XXX-XXXX or send an email to
[email protected] to take part in the study. Mathematica will send you a $20 gift
card for participating as a thank you.
You can read about the study at https://www.ssa.gov/disabilityresearch/nbs_participants.html.
You can contact me at [FILL NAME]@SSA.gov if you have any questions or concerns.
We look forward to speaking with you. Thank you for your help.
Sincerely,

FILL NAME
Office of Research, Demonstration, and
Employment Support
Office of Retirement and Disability Policy

Privacy Act Statement
Collection and Use of Personal Information

Public Law 106-170 Section 101 (1)(d)(4)(C)(i), allows us to collect this information. We will
use your answers to learn more about disability beneficiaries, how well our programs are
working, and design new programs. The information will solely be used for research purposes to
improve SSA's programs and policies.
Participation is voluntary and participating or not participating will not affect your benefits.
We use the information you supply primarily for the purposes stated above. However, we may
use it for the administration and integrity of our programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but
are not limited to the following:
1. To comply with Federal laws requiring the release of information from Social Security
records (e.g. to the Government Accountability Office and Department of Veterans
Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs, including responding to
questions from Congress.
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0058, Master Files of Social Security
Number (SSN) Holders and SSN Applications. Additional information about this and other
system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.

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 for this collection is 0960-XXXX; expiration date XX/XX/XXXX. We estimate that it
will take about 60 minutes to read the instructions, and answer the questions. You may send
comments on our time estimate to: Social Security Administration, 6401 Security Blvd,
Baltimore, MD 21235-6401.

SOCIAL SECURITY
Para información e instrucciones en español, llame XXX-XXX-XXXX por favor.
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
There is still time to participate in the National Beneficiary Survey (NBS), sponsored by the
Social Security Administration. This study will tell us about people who use Social Security
Disability Insurance (SSDI) or Supplemental Security Income (SSI). Sharing your experiences
will help us make our programs better.
If you already took part in the study, thank you. If you have not yet taken part, please do so
today. We hired a company called Mathematica Policy Research to help us with this study. You
can call them toll-free at 877-XXX-XXXX or send an email to [email protected]
to take part in the study.
As a thank you, Mathematica will send you a $20 gift card for participating.
Taking part in the NBS is your choice. We will not share your answers in any way that reveals
who you are. We will not use your answers to make changes to your benefits. We will use your
information only for research.
You can read about the study at https://www.ssa.gov/disabilityresearch/nbs_participants.html.
You can contact me at [FILL NAME]@SSA.gov if you have any questions or concerns.
We look forward to speaking with you. Thank you for your help.
Sincerely,

FILL NAME
Office of Research, Demonstration, and
Employment Support
Office of Retirement and Disability Policy

Privacy Act Statement
Collection and Use of Personal Information

Public Law 106-170 Section 101 (1)(d)(4)(C)(i), allows us to collect this information. We will
use your answers to learn more about disability beneficiaries, how well our programs are
working, and design new programs. The information will solely be used for research purposes to
improve SSA's programs and policies.
Participation is voluntary and participating or not participating will not affect your benefits.
We use the information you supply primarily for the purposes stated above. However, we may
use it for the administration and integrity of our programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but
are not limited to the following:
1. To comply with Federal laws requiring the release of information from Social Security
records (e.g. to the Government Accountability Office and Department of Veterans
Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs, including responding to
questions from Congress.
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0058, Master Files of Social Security
Number (SSN) Holders and SSN Applications. Additional information about this and other
system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.

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 for this collection is 0960-XXXX; expiration date XX/XX/XXXX. We estimate that it
will take about 60 minutes to read the instructions, and answer the questions. You may send
comments on our time estimate to: Social Security Administration, 6401 Security Blvd,
Baltimore, MD 21235-6401.

SOCIAL SECURITY
Para información e instrucciones en español, llame XXX-XXX-XXXX por favor.
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
This is your last chance to participate in the National Beneficiary Survey (NBS), sponsored by
the Social Security Administration. We really need to hear from you! This study will tell us
about people who use Social Security Disability Insurance (SSDI) or Supplemental Security
Income (SSI). Sharing your experiences will help us make our programs better.
If you already took part in the study, thank you. If you have not yet taken part, please do so
today. We hired a company called Mathematica Policy Research to help us with this study. You
can call them toll-free at 877-XXX-XXXX or send an email to [email protected]
to take part in the study.
As a thank you, Mathematica will send you a $20 gift card for participating.

You can read about the study at https://www.ssa.gov/disabilityresearch/nbs participants.html.
You can contact me at [FILL NAME]@SSA.gov if you have any questions or concerns.
We look forward to speaking with you. Thank you for your help.
Sincerely,

FILL NAME
Office of Research, Demonstration, and
Employment Support
Office of Retirement and Disability Policy

Privacy Act Statement
Collection and Use of Personal Information

Public Law 106-170 Section 101 (1)(d)(4)(C)(i), allows us to collect this information. We will
use your answers to learn more about disability beneficiaries, how well our programs are
working, and design new programs. The information will solely be used for research purposes to
improve SSA's programs and policies.
Participation is voluntary and participating or not participating will not affect your benefits.
We use the information you supply primarily for the purposes stated above. However, we may
use it for the administration and integrity of our programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but
are not limited to the following:
1. To comply with Federal laws requiring the release of information from Social Security
records (e.g. to the Government Accountability Office and Department of Veterans
Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs, including responding to
questions from Congress.
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0058, Master Files of Social Security
Number (SSN) Holders and SSN Applications. Additional information about this and other
system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.

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 for this collection is 0960-XXXX; expiration date XX/XX/XXXX. We estimate that it
will take about 60 minutes to read the instructions, and answer the questions. You may send
comments on our time estimate to: Social Security Administration, 6401 Security Blvd,
Baltimore, MD 21235-6401

ATTACHMENT B4
REMINDER POSTCARDS

ATTACHMENT B5
REFUSAL LETTERS

REFUSAL LETTER—GENERIC

SOCIAL SECURITY
Para información e instrucciones en español, llame XXX-XXX-XXXX por favor.
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
We need your help with an important study, the National Beneficiary Survey (NBS). The NBS
asks about your health, work, and services you may have gotten in the past year. The goal is to
make programs better for people who get Social Security Disability Insurance (SSDI) or
Supplemental Security Income (SSI).
We hired a company called Mathematica Policy Research to help us with this study. They
recently called you but were not able to interview you. I am writing today to ask you to again
think about taking part in this important study.
This is your chance to tell us what you think and to make your voice heard. Hearing from a lot of
different people will help us improve our programs for everyone. Many people find the questions
interesting and enjoy the interview. Mathematica will send you a $20 gift card as a thank you
after you finish the survey.
You can call Mathematica toll-free at 877-XXX-XXXX if you have questions about taking part
in the study or if you would like to speak with an interviewer. One of Mathematica’s
interviewers will contact you again within the next few weeks.
If you have any questions or concerns, please contact me at [FILL NAME]@SSA.gov.
I hope that you will choose to participate.

Sincerely,

FILL NAME
Office of Research, Demonstration, and
Employment Support
Office of Retirement and Disability Policy

REFUSAL LETTER—GENERIC
Privacy Act Statement
Collection and Use of Personal Information

Public Law 106-170 Section 101 (1)(d)(4)(C)(i), allows us to collect this information. We will
use your answers to learn more about disability beneficiaries, how well our programs are
working, and design new programs. The information will solely be used for research purposes to
improve SSA's programs and policies.
Participation is voluntary and participating or not participating will not affect your benefits.
We use the information you supply primarily for the purposes stated above. However, we may
use it for the administration and integrity of our programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but
are not limited to the following:
1. To comply with Federal laws requiring the release of information from Social Security
records (e.g. to the Government Accountability Office and Department of Veterans
Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs, including responding to
questions from Congress.
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0058, Master Files of Social Security
Number (SSN) Holders and SSN Applications. Additional information about this and other
system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.

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 for this collection is 0960-XXXX; expiration date XX/XX/XXXX. We estimate that it
will take about 60 minutes to read the instructions, and answer the questions. You may send
comments on our time estimate to: Social Security Administration, 6401 Security Blvd,
Baltimore, MD 21235-6401.

REFUSAL LETTER—CONFIDENTIALITY

SOCIAL SECURITY
Para información e instrucciones en español, llame XXX-XXX-XXXX por favor.
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
We need your help with an important study, the National Beneficiary Survey (NBS). The NBS
asks about your health, work, and services you may have gotten in the past year. The goal is to
make programs better for people who get Social Security Disability Insurance (SSDI) or
Supplemental Security Income (SSI).
We hired a company called Mathematica Policy Research to help us with this study. They
recently called you but were not able to interview you. I am writing today to ask you to again
think about taking part in this important study.
When Mathematica called, you said that you were concerned about the privacy of your answers.
I promise you that your answers will not be shared in any way that reveals who you are.
Protecting your privacy is one of our main concerns. During the interview, if there is a question
you do not want to answer, tell the interviewer you want to skip it.
We want to talk to people with different experiences and backgrounds. This will help us make
our programs better for everyone. We need your help to make this study a success. Mathematica
will send you a $20 gift card as a thank you after you finish the survey.
You can call Mathematica toll-free at 877-XXX-XXXX if you have questions about taking part
in the study or if you would like to speak with an interviewer. One of Mathematica’s
interviewers will contact you again within the next few weeks.
If you have any questions or concerns, please contact me at [FILL NAME]@SSA.gov.
I hope that you will choose to participate.
Sincerely,

FILL NAME
Office of Research, Demonstration, and
Employment Support
Office of Retirement and Disability Policy

REFUSAL LETTER—CONFIDENTIALITY
Privacy Act Statement
Collection and Use of Personal Information

Public Law 106-170 Section 101 (1)(d)(4)(C)(i), allows us to collect this information. We will
use your answers to learn more about disability beneficiaries, how well our programs are
working, and design new programs. The information will solely be used for research purposes to
improve SSA's programs and policies.
Participation is voluntary and participating or not participating will not affect your benefits.
We use the information you supply primarily for the purposes stated above. However, we may
use it for the administration and integrity of our programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but
are not limited to the following:
1. To comply with Federal laws requiring the release of information from Social Security
records (e.g. to the Government Accountability Office and Department of Veterans
Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs, including responding to
questions from Congress.
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0058, Master Files of Social Security
Number (SSN) Holders and SSN Applications. Additional information about this and other
system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.

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 for this collection is 0960-XXXX; expiration date XX/XX/XXXX. We estimate that it
will take about 60 minutes to read the instructions, and answer the questions. You may send
comments on our time estimate to: Social Security Administration, 6401 Security Blvd,
Baltimore, MD 21235-6401.

REFUSAL LETTER—TOO LONG

SOCIAL SECURITY
Para información e instrucciones en español, llame XXX-XXX-XXXX por favor.
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
We need your help with an important study, the National Beneficiary Survey (NBS). The NBS
asks about your health, work, and services you may have gotten in the past year. The goal is to
make programs better for people who get Social Security Disability Insurance (SSDI) or
Supplemental Security Income (SSI).
We hired a company called Mathematica Policy Research to help us with this study. They
recently called you but were not able to interview you. I am writing today to ask you to again
think about taking part in this important study.
When Mathematica called, you said you thought the interview would take too long. Your input is
important. Hearing from a lot of different people will help us improve our programs for
everyone. Mathematica will work with you to make sure your voice is heard. They can set up the
interview for a time that works for you. You can also complete the interview in more than one
call. If you begin to feel tired or are not feeling well enough to be interviewed, Mathematica will
call you back to continue the interview at another time. Mathematica will send you a $20 gift
card as a thank you after you finish the survey.
You can call Mathematica toll-free at 877-XXX-XXXX if you have questions about taking part
in the study or if you would like to speak with an interviewer. One of Mathematica’s
interviewers will contact you again within the next few weeks.
If you have any questions or concerns, please contact me at [FILL NAME]@SSA.gov.
I hope that you will choose to participate.
Sincerely,

FILL NAME
Office of Research, Demonstration, and
Employment Support
Office of Retirement and Disability Policy

REFUSAL LETTER—TOO LONG
Privacy Act Statement
Collection and Use of Personal Information

Public Law 106-170 Section 101 (1)(d)(4)(C)(i), allows us to collect this information. We will
use your answers to learn more about disability beneficiaries, how well our programs are
working, and design new programs. The information will solely be used for research purposes to
improve SSA's programs and policies.
Participation is voluntary and participating or not participating will not affect your benefits.
We use the information you supply primarily for the purposes stated above. However, we may
use it for the administration and integrity of our programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but
are not limited to the following:
1. To comply with Federal laws requiring the release of information from Social Security
records (e.g. to the Government Accountability Office and Department of Veterans
Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs, including responding to
questions from Congress.
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0058, Master Files of Social Security
Number (SSN) Holders and SSN Applications. Additional information about this and other
system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.

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 for this collection is 0960-XXXX; expiration date XX/XX/XXXX. We estimate that it
will take about 60 minutes to read the instructions, and answer the questions. You may send
comments on our time estimate to: Social Security Administration, 6401 Security Blvd,
Baltimore, MD 21235-6401.

REFUSAL LETTER—NOT INTERESTED

SOCIAL SECURITY
Para información e instrucciones en español, llame XXX-XXX-XXXX por favor.
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
We need your help with an important study, the National Beneficiary Survey (NBS). We hired
Mathematica Policy Research to help us with this study. Mathematica is a well-known research
company with offices in New Jersey, Washington, DC and other places around the country. You
can visit Mathematica’s at www.mathematica-mpr.com.
Mathematica called you about a week ago but was not able to talk with you. I am writing to let
you know that being in this study matters. You can help us learn about the experiences and
needs of people who receive or who used to receive disability benefits – this will help us make
our programs better for everyone. This is your chance to tell us what you think and to make your
voice heard. Many people find the questions interesting and enjoy the interview. Mathematica
will send you a $20 gift card as a thank you after you finish the survey.
You can call Mathematica toll-free at 877-XXX-XXXX if you have questions about taking part
in the study or if you would like to speak with an interviewer. One of Mathematica’s
interviewers will contact you again within the next few weeks.
If you have any questions or concerns, please contact me at [FILL NAME]@SSA.gov.
I hope that you will choose to participate.

Sincerely,

FILL NAME
Associate Commissioner
Office of Research, Demonstration, and
Employment Support
Office of Retirement and Disability Policy

REFUSAL LETTER—NOT INTERESTED
Privacy Act Statement
Collection and Use of Personal Information

Public Law 106-170 Section 101 (1)(d)(4)(C)(i), allows us to collect this information. We will
use your answers to learn more about disability beneficiaries, how well our programs are
working, and design new programs. The information will solely be used for research purposes to
improve SSA's programs and policies.
Participation is voluntary and participating or not participating will not affect your benefits.
We use the information you supply primarily for the purposes stated above. However, we may
use it for the administration and integrity of our programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but
are not limited to the following:
1. To comply with Federal laws requiring the release of information from Social Security
records (e.g. to the Government Accountability Office and Department of Veterans
Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs, including responding to
questions from Congress.
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0058, Master Files of Social Security
Number (SSN) Holders and SSN Applications. Additional information about this and other
system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.

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 for this collection is 0960-XXXX; expiration date XX/XX/XXXX. We estimate that it
will take about 60 minutes to read the instructions, and answer the questions. You may send
comments on our time estimate to: Social Security Administration, 6401 Security Blvd,
Baltimore, MD 21235-6401.

ATTACHMENT B6
PREFIELD LETTER

SOCIAL SECURITY
Para información e instrucciones en español, llame XXX-XXX-XXXX por favor.
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
We need your help with an important study sponsored by the Social Security Administration, the
National Beneficiary Survey (NBS). The NBS asks about your health, work, and services you
may have gotten in the past year. The goal is to make programs better for people who get Social
Security Disability Insurance (SSDI) or Supplemental Security Income (SSI).
We hired a company called Mathematica Policy Research to help us with this study. They are a
national research firm that conducts surveys for federal, state, and local governments on
important policy issues. Mathematica has tried calling you, but has not been able to reach you.
Taking part in the NBS is your choice. We will not share your answers in any way that reveals
who you are. We will not use your answers to make changes to your benefits. We will use your
information only for research. We want to talk to people with different experiences and
backgrounds. This will help us make our programs better for everyone.
In about one week, an interviewer from Mathematica will visit you at your home to make it
easier for you to take part in the survey. Mathematica will give you a $20 gift card as a thank
you after you finish the survey.
Taking part in this survey is easy. You can call Mathematica toll-free at 877-XXX-XXXX to
set up a time to be interviewed. You can also contact Mathematica by sending an email with
your name and telephone number to [email protected]. You can contact me
directly at [FILL NAME]@SSA.gov if you have any questions or concerns.
Thank you for your participation. We need your help to make this study a success.
Sincerely,

FILL NAME
Office of Research, Demonstration, and
Employment Support
Office of Retirement and Disability Policy

Privacy Act Statement
Collection and Use of Personal Information

Public Law 106-170 Section 101 (1)(d)(4)(C)(i), allows us to collect this information. We will
use your answers to learn more about disability beneficiaries, how well our programs are
working, and design new programs. The information will solely be used for research purposes to
improve SSA's programs and policies.
Participation is voluntary and participating or not participating will not affect your benefits.
We use the information you supply primarily for the purposes stated above. However, we may
use it for the administration and integrity of our programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but
are not limited to the following:
1. To comply with Federal laws requiring the release of information from Social Security
records (e.g. to the Government Accountability Office and Department of Veterans
Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs, including responding to
questions from Congress.
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0058, Master Files of Social Security
Number (SSN) Holders and SSN Applications. Additional information about this and other
system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.

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 for this collection is 0960-XXXX; expiration date XX/XX/XXXX. We estimate that it
will take about 60 minutes to read the instructions, and answer the questions. You may send
comments on our time estimate to: Social Security Administration, 6401 Security Blvd,
Baltimore, MD 21235-6401.

ATTACHMENT B7
LOCATING LETTER

SOCIAL SECURITY
Para información e instrucciones en español, llame XXX-XXX-XXXX por favor.
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
We have been trying to reach you. We need your help with an important study sponsored by
the Social Security Administration. It is about your health, work, and the things you do each
day. We hired a company called Mathematica Policy Research to help us with this study.
Mathematica would like to interview you, but they do not have your current phone number.
Please call Mathematica toll-free at 877-XXX-XXXX to set up a time to be interviewed. You
will get a $20 gift card after you complete the interview as a thank you. You can also
contact Mathematica by sending an email with your name and telephone number to
[email protected]. You can contact me directly at [FILL NAME]@SSA.gov if
you have any questions or concerns.
We look forward to hearing from you.

Sincerely,

FILL NAME
Office of Research, Demonstration, and
Employment Support
Office of Retirement and Disability Policy

Privacy Act Statement
Collection and Use of Personal Information

Public Law 106-170 Section 101 (1)(d)(4)(C)(i), allows us to collect this information. We will
use your answers to learn more about disability beneficiaries, how well our programs are
working, and design new programs. The information will solely be used for research purposes to
improve SSA's programs and policies.
Participation is voluntary and participating or not participating will not affect your benefits.
We use the information you supply primarily for the purposes stated above. However, we may
use it for the administration and integrity of our programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but
are not limited to the following:
1. To comply with Federal laws requiring the release of information from Social Security
records (e.g. to the Government Accountability Office and Department of Veterans
Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs, including responding to
questions from Congress.
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0058, Master Files of Social Security
Number (SSN) Holders and SSN Applications. Additional information about this and other
system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.

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 for this collection is 0960-XXXX; expiration date XX/XX/XXXX. We estimate that it
will take about 60 minutes to read the instructions, and answer the questions. You may send
comments on our time estimate to: Social Security Administration, 6401 Security Blvd,
Baltimore, MD 21235-6401.

ATTACHMENT B8
HIPAA LETTER

SOCIAL SECURITY
REPRESENTATIVE NAME
ORGANIZATION
ADDRESS
CITY, STATE ZIP
Dear NAME:
Thank you for your interest in the National Beneficiary Survey (NBS). The NBS is an
important study that collects information about the programs and services used by people
with disabilities. The survey asks about their health and well-being and about their
experiences in finding and keeping a job. The NBS is being conducted to help us assess how
well our programs are meeting the needs of beneficiaries.
was randomly
selected to take part in this study. Although ’s
cooperation is voluntary, we would greatly appreciate help.
As a contractor to SSA, Mathematica Policy Research is conducting the NBS, a function
that is classified as a “public health authority action.” This allows Mathematica to access
protected health information (PHI) under the Health Insurance Portability and
Accountability Act (HIPAA) Privacy Rule [45 CFR 160-164]. Although this classification
permits access to PHI without a waiver from an institutional review board or privacy board,
and it does not require individual authorization to obtain PHI, I want to assure you that
Mathematica follows the strict standards specified by HIPAA for collecting health
information for research purposes. It is Mathematica’s policy that any information provided
by research participants will be kept strictly confidential. Furthermore, SSA will not use the
information to make any decisions about a participant’s receipt of disability benefits.
Information is being collected for research purposes only.
We would like to interview by telephone. This
interview will take about 60 minutes, on average, to complete. As a token of our
appreciation, Mathematica will send a gift card for
$20 after completes the interview. If is
unable to participate, we may be able to interview someone on behalf who is
familiar with health, education, and experience with SSA programs.
If you have questions about this study or ’s
participation, please call Mathematica toll-free at 877-XXX-XXXX or send an email to
[email protected]. To learn more about this study, you can visit SSA’s
website at https://www.ssa.gov/disability research/ nbs_participants.html. You can also call
me directly at [FILL NUMBER] or email [FILL NAME]@SSA.gov if you have any
questions or concerns.
Thank you for your assistance.
Sincerely,

FILL NAME
Office of Research, Demonstration, and
Employment Support
Office of Retirement and Disability Policy

Privacy Act Statement
Collection and Use of Personal Information

Public Law 106-170 Section 101 (1)(d)(4)(C)(i), allows us to collect this information. We will
use your answers to learn more about disability beneficiaries, how well our programs are
working, and design new programs. The information will solely be used for research purposes to
improve SSA's programs and policies.
Participation is voluntary and participating or not participating will not affect your benefits.
We use the information you supply primarily for the purposes stated above. However, we may
use it for the administration and integrity of our programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include but
are not limited to the following:
1. To comply with Federal laws requiring the release of information from Social Security
records (e.g. to the Government Accountability Office and Department of Veterans
Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs, including responding to
questions from Congress.
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0058, Master Files of Social Security
Number (SSN) Holders and SSN Applications. Additional information about this and other
system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.

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 for this collection is 0960-XXXX; expiration date XX/XX/XXXX. We estimate that it
will take about 60 minutes to read the instructions, and answer the questions. You may send
comments on our time estimate to: Social Security Administration, 6401 Security Blvd,
Baltimore, MD 21235-6401.

ATTACHMENT B9
THANK YOU LETTER

1100 1st Street, NE, 12th Floor
Washington, DC 20002-4221
Telephone (202) 484-9220
Fax (202) 863-1763
www.mathematica-mpr.com

Dear Study Participant,
Thank you for your help with the National Beneficiary Survey. The information from this
important study will help the Social Security Administration evaluate how well its programs are
meeting the needs of disability beneficiaries.
As a token of our appreciation we have enclosed a $20 gift card. If you have any questions,
please call Mathematica at 877-XXX-XXXX or send an email to [email protected].
Sincerely,
[SIGNATURE]
Title