Form FEMA Form 519-0-41 FEMA Form 519-0-41 Assessment Survey (Electronic)

D raft: Assessment Survey- Electronic

OMB Control Number 1660-NEW

Expiration Date

PAPERWORK BURDEN DISCLOSURE NOTICE: Public reporting burden for this survey is estimated to average 13 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 the quality of our services and your opinion is very important. This questionnaire should be completed by the person in the household most familiar with the FEMA application. The survey will take 8-10 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 (New OMB Number). 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)

FEMA is interested in feedback on your experiences following the [Disaster Type] disaster declared on [Declared Date].

INFORMATION & COMMUNICATIONS

The first set of questions are about FEMA disaster assistance information.

1. Which one of the following was your main source of information about FEMA programs?

• FEMA.gov or DisasterAssistance.gov websites

• FEMA disaster workers

• Non-Profit organizations like American Red Cross, churches, schools, etc.

• TV, radio, newspapers

• Friends, family or neighbors

(Programmer Note: If Q1 response = FEMA.gov or DisasterAssistance.gov websites, or FEMA disaster workers, go to Q2 else go to Q8)

Using a rating scale of 1 to 5, with 1 being Poor and 5 being Excellent, please rate [Q1 response] information on the following:

	1 Poor	2	3	4	5 Excellent
2. Being easy to understand
3. Answering your questions
4. Being helpful in your recovery
5. Explaining what happens next
6. Timeliness
7. Overall satisfaction with information

The next set of questions is about letters or other materials you received from FEMA by US Mail or electronic communications. Please use a rating scale of 1 to 5, with 1 being Poor and 5 being Excellent. Say No Experience, if any of the questions do not apply to you. How would you rate FEMA correspondence on the following:

	1 Poor	2	3	4	5 Excellent	No Experience
8. Clearly explaining eligible or ineligible decisions
9. Clearly explaining the purpose of the funds
10. Explaining the appeal process
11. Timely delivery of the correspondence
12. Being easy to understand
13. Overall satisfaction with FEMA correspondence

(Programmer Note: If HA and/or ONA = Y go to Q14, If HA and ONA = N go to Q17)

ASSISTANCE & RECOVERY

FEMA may provide grants for home repairs and rental assistance. Grants may also be provided for Personal Property like a vehicle, household items, child care as well as medical, dental and funeral expenses. For the next questions please use a rating scale of 1 to 5, with 1 being Poor and 5 being Excellent. How would you rate FEMA financial assistance in…

	1 Poor	2	3	4	5 Excellent
14. Arriving in a reasonable amount of time
15. Helping meet your disaster related needs

(Programmer Note: If Q15 response = 1 or 2 go to Q16 else go to Q17)

16. Which one of the following best describes the area where FEMA financial assistance did not meet your disaster related needs?

• Home repairs

• Rental assistance

• Personal Property

• Child Care expenses

• Medical, Dental or Funeral expenses

• None of the above

(Programmer Note: If Q16 response = None of the above go to Q17 else go to Q16a)

16a.Which one of the following best describes why your disaster related needs for [Q16 Response] were not met?

• Some damages were not eligible for FEMA assistance

• Amount of FEMA financial assistance was too little

• Repair or replacement costs were too high

• FEMA appeal is pending

• None of the above

The next questions relate to your progress in recovering from the impacts of the disaster. Using a rating scale of 1 to 5, with 1 being Not at all Recovered and 5 being Completely Recovered…

	1 Not at all Recovered	2	3	4	5 Completely Recovered
17. How would you rate your current level of recovery?

(Programmer Note: If Q17 response = 1, 2 or 3 go to Q18, if Q17 response = 4 or 5 and inspection date is not null go to Q19, if inspection date is null go to Q23)

18. Which of the following are primary causes for delays in your recovery:

• Money for home repairs

• Money for personal property

• Money to move to a new residence

• Delayed or denied insurance settlement

• Delayed FEMA appeal

• Lack of affordable and accessible housing

• Lack of time to make repairs

• Lack of contractors and or materials

• Medical or disability conditions

• Unemployed as a result of the disaster

INSPECTION

The next questions relate to the FEMA inspection conducted on [Inspection Date]. Please use a rating scale of 1 to 5, with 1 being Not at all Satisfied and 5 being Very Satisfied. How satisfied were you with the…

	1 Not at all Satisfied	2	3	4	5 Very Satisfied
19. Timeliness of the inspection
20. Professionalism of the inspector
21. Helpfulness of the inspector
22. Overall inspection experience

CUSTOMER SERVICE & EXPECTATIONS

The next questions relate to all of your experiences with FEMA. Using a rating scale of 1 to 5, with 1 being Poor and 5 being Excellent, how would you rate FEMA on providing…

	1 Poor	2	3	4	5 Excellent
23. Caring customer service
24. Easy access to services
25. Easy to understand disaster assistance information
26. Information in your preferred language
27. And on meeting your expectations

28. Which one of the following is your preferred method for interacting with FEMA?

• Internet

• In Person

• By Telephone

DEMOGRAPHICS

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

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

• Yes

• No

(Programmer Note: If Q29 response = Yes go to Q30 else go to Q36)

30. Is your gender…

• Female

• Male

• Prefer not to answer

31. 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

32. Is your marital status…

• Single

• Married

• Separated

• Widowed

• Divorced

• Prefer not to answer

33. Is your current employment status…

• Employed for wages

• Self-employed

• Unemployed

• Homemaker

• Student

• Retired

• Prefer not to answer

34. Which one of the following best describes your 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

35. Which of the following is your race or 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

36. What suggestions do you have for improving FEMA assistance? (250 characters or less)

37. 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.