FEMA Form 519-0-37

D RAFT: Initial Survey – Electronic

OMB Control Number 1660-New

Expiration Date

PAPERWORK BURDEN DISCLOSURE NOTICE: Public reporting burden for this survey is estimated to average 8 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting the survey. You are not required to respond to this collection of information unless it displays a valid OMB control number near the title of the electronic collection instrument, or for on-line applications, on the first screen viewed by the respondents. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW, Washington, DC 20472, Paperwork Reduction Project (1660-NEW) NOTE: Do not send your completed form to this address.

The following survey is voluntary.

PRIVACY ACT STATEMENT

AUTHORITY: Government Performance and Results Act of 1993 (Pub. L. 103-62), as amended, and the GPRA Modernization Act of 2010 (Pub. L. 111-352); Executive Order (EO) 12862, “Setting Customer Service Standards”; and its March 23, 1995 Memorandum addendum, “Improving Customer Service”; Executive Order 13411 “Improving Assistance for Disaster Victims”; Executive Order 13571 “Streamlining Service Delivery and Improving Customer Service”; and the related June 13, 2011 Memorandum “Implementing Executive Order 13571 on Streamlining Service Delivery and Improving Customer Service.”

PRINCIPAL PURPOSE(S): DHS/FEMA collects this information to measure Individual Assistance applicants’ customer satisfaction with FEMA services.

ROUTINE USE(S): This information is used for the principal purpose noted above and will not be shared outside of DHS/FEMA, except as allowed under the routine uses published in System of Records Notice DHS/FEMA-008 - Disaster Recovery Assistance Files, 78 FR 25282 (April 30, 2013), or as required by law. The Department's system of records notices can be found on the Department's website at http://www.dhs.gov/system-records-notices-sorns.

DISCLOSURE: The disclosure of information on this form is strictly voluntary and will assist FEMA is making improvements to its Individual Assistance program; failure to provide the information requested will not impact an individual’s ability to qualify for or receive FEMA Individual Assistance.

FEMA Form XXX-X-X (Electronic)

Introduction – Electronic (Applicable for sample records where the applicant requested electronic correspondence from FEMA)

FEMA is looking for ways to improve services and your opinion is very important. This questionnaire should be completed by the person in the household who applied for FEMA disaster assistance on [Application Date].

The survey is voluntary and will take 5-8 minutes to complete.

These questions comply with the Privacy Act of 1974 and have been approved by the Office of Management and Budget under number TBD. Your answers will not affect the outcome of your application for FEMA assistance.

Please click Next to begin the survey:

FEMA Form XXX-X-X (Electronic)

INFORMATION

The first questions are about information provided to you during the FEMA application process. Using a rating scale of 1 to 5, with 1 being Poor and 5 being Excellent, please rate the information on…

	1 Poor	2	3	4	5 Excellent
1. Being easy to understand
2. Answering your questions
3. Providing helpful referrals to other agencies or organizations
4. Explaining what happens next
5. Overall satisfaction with the information

(Programmer note: If Type flag = Phone or DSAT go to Q6 if Internet go to Q10)

CUSTOMER SERVICE

The next set of questions are about the level of customer service provided by the FEMA representative who assisted with your application. Using the same rating scale of 1 to 5, with 1 being Poor and 5 being Excellent, please rate the representative on the following:

	1 Poor	2	3	4	5 Excellent
6. Courtesy
7. Showing interest in helping
8. Overall customer service

(Programmer Note: If Type Flag = DSAT go to Q14))

For the next item, please think back to your experience calling FEMA’s toll free number. Using a rating scale of 1 to 5, with 1 being Not at all Satisfied and 5 being Very Satisfied…

	1 Not at all Satisfied	2	3	4	5 Very Satisfied
9. How satisfied were you with the amount of time it took for a FEMA representative to answer your call?

(Programmer Note: If Q9 response = 1 or 2 go to Q9a, else go to Q14)

9a.Which of the following would you consider an acceptable amount of time to wait for a FEMA representative to answer your call?

• Less than 2 minutes

• 2 – 3 minutes

• 3 - 5 minutes

• 5 – 7 minutes

• More than 7 minutes

(Programmer Note: go to Q14)

FEMA APPLICATION AT DISASTERASSISTANCE.GOV

The next set of questions are about applying for FEMA assistance online at the DisasterAssistance.gov website. Please use a rating scale of 1 to 5, with 1 being Not at all Easy and 5 being Very Easy. If you had no experience with any of the services just say No Experience. How would you rate the simplicity of…

	1 Not at all Easy	2	3	4	5 Very Easy	No Experience
10. Finding where to apply online
11. Navigating the website
12. Finding helpful Information
13. Using the Technical Help Desk

Using a rating scale of 1 to 5, with 1 being Not at all easy and 5 being Very Easy…

	1 Not at all Easy	2	3	4	5 Very Easy
14. How would you rate the simplicity of completing your application for FEMA assistance?

(Programmer Note: If Q14 response = 1 or 2 go to Q14a else go to Q15.

14a.Which one of the following best describes why the FEMA application was not easy to complete…

• Took too long

• Questions were not easy to understand

• Terminology was confusing

• Information requested was not easily available

• None of the above

DISASTER RECOVERY CENTER

15. Did you recently visit a FEMA Disaster Recovery Center?

• Yes

• No

(Programmer Note: If Q15 response = Yes go to Q16 else go to Q25)

16. Which one of the following was your main source of information about FEMA Disaster Recovery Center locations and services?

• Community group (club, church, school etc.)

• Disaster workers

• Flyers, signs, billboards, posters, etc.

• Newspaper, radio, television

• Word of mouth (like friends, family, neighbors, employer, landlord, etc.)

• FEMA website

• Social media

• None of the above

Using a rating scale of 1 to 5, with 1 being Poor and 5 being Excellent, how would you rate the Disaster Recovery Center on the following:

	1 Poor	2	3	4	5 Excellent
17. Public awareness of the center
18. Location
19. Hours of operation
20. Easy to understand brochures and materials
21. Organization
22. Efficiency
23. Caring customer service
24. Overall satisfaction

(Programmer Note: If Q24 response = 1 or 2 go to Q24a else go Q25)

24a.What recommendations do you have for improving FEMA Disaster Recovery Center services?

Demographics

The next set of questions are related to demographics data and are used only for statistical purposes.

25. Would you volunteer to take an additional 2-3 minutes to answer these questions?

• Yes

• No

(Programmer Note: If Q25 response = Yes go to Q26 else go to Q32)

26. Is your gender…

• Female

• Male

• Prefer not to answer

27. Is your age range…

• Under 25

• 25 to 34

• 35 to 44

• 45 to 54

• 55 to 64

• 65 to 74

• 75 or older

• Prefer not to answer

28. Is you marital status…

• Single

• Married

• Separated

• Widowed

• Divorced

• Prefer not to answer

29. Is your current employment status…

• Employed for wages

• Self-employed

• Unemployed

• Homemaker

• Student

• Retired

• Prefer not to answer

30. Which of the following best describes you highest level of formal education

• Did not complete high school

• High school graduate / GED

• Some college

• Associate degree

• Bachelor’s degree

• Master’s degree

• Doctoral degree

• Prefer not to answer

31. Which of the following is your race and ethnic group? You may select all that apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Hispanic or Latino

• Native Hawaiian or Other Pacific Islander

• White, Not Hispanic or Latino

• Prefer not to answer

32. Your opinion is very valuable to us. May we contact you at a later date to ask additional questions?

• Yes

• No

CLOSING ELECTRONIC SURVEY

Thank you for your time. Have a good day/evening.