Form 250 2019 250 SSA Field Office Survey_12.19.19_Final.xlsx

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Overview

Welcome and Thank You Text
Model Questions
Custom Questions

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Sheet 1: Welcome and Thank You Text

	The text you see here will appear at the top and bottom of your survey, examples below.
	Default text is included and you may modify this text as needed.
	Welcome and Thank You Text
		Welcome Text
		Thank You Text
		Thank you for taking our survey - and for helping us serve you better. Please note you will not receive a response from us based on your survey comments. If you would like us to contact you about your feedback, please visit the Contact Us section of our website.
		Example Desktop

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Sheet 2: Model Questions

Model Name		SSA Field Office					Red & Strike-Through: Delete
Model ID		QpUwMkFBwwF9tsMB5NtdQQ4C					Underlined & Italicized: Re-order
Partitioned		No					Pink: Addition
Date		11/5/2019					Blue: Reword
Model Version		Custom
	Label	Satisfaction Questions		Label	Element Questions		Label	Future Behaviors
		Satisfaction			Accessibility (1=Poor, 10=Excellent, Don't Know)			Visit Again (1=Very Unlikely, 10=Very Likely)
1	Satisfaction - Overall	What is your overall satisfaction with this Social Security office visit? (1=Very Dissatisfied, 10=Very Satisfied)	5	Accessibility - Convenience	Please rate your experience receiving customer service at the Social Security office in the following areas: The convenience of receiving customer service at the Social Security office relative to the telephone or website.	15	Visit Again	How likely are you to visit this office again for your Social Security Administration service needs in the future?
2	Satisfaction - Expectations	How well did your Social Security office visit meet your expectations? (1=Fell Short, 10=Exceeded)	6	Accessibility - Easy Connection	The ease of meeting with a representative
3	Satisfaction - Ideal	How well did your Social Security office visit compare to an ideal customer service experience? (1=Not Very Close, 10=Very Close)	7	Accessibility - Wait Time	Amount of time spent waiting for a representative
		Recommend (NPS) (1=Very Unlikely, 10=Very Likely)			Service Representative (1=Poor, 10=Excellent, Don't Know)
4	Recommend	How likely are you to recommend this Social Security office visit experience to someone else?	8	Representative - Understanding	Please rate the representative who assisted you in the following areas: Understanding of your issue or request
			9	Representative - Empathy	Recognition of the importance of your issue or request
			10	Representative - Knowledge	Level of knowledge regarding your issue or request
			11	Representative - Authority	Level of authority to resolve your issue or request on their own
					Service Resolution
			12	Service Resolution - Complete	Please rate the response provided to your request or question in the following areas: The extent to which your issue or request was resolved (1=Not Resolved at all, 10=Completely Resolved, Don't Know)
			13	Service Resolution - Thoroughness	Thoroughness of any information provided (1=Poor, 10=Excellent, Don't Know)
			14	Service Resolution - Efficiency	Efficiency of the service provided (1=Poor, 10=Excellent, Don't Know)

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Sheet 3: Custom Questions

SSA Field Office				Red & Strike-Through: Delete
QpUwMkFBwwF9tsMB5NtdQQ4C				Underlined & Italicized: Re-order
No				Pink: Addition
11.27.19				Blue: Reword
Skip From	Question Text	Answer Choices	Skip To	Required Y/N	Type	Special Instructions	CQ Label
	Please indicate your level of agreement with the following statements about your interaction today: I am satisfied with the service I received from the Social Security Administration.	1=Strongly Disagree		Y	Radio button, scale, no don't know		A11-Satisfied
		2
		3
		4
		Strongly Agree=5
	This interaction increased my confidence in the Social Security Administration.	1=Strongly Disagree		Y	Radio button, scale, no don't know		A11-Trust
		2
		3
		4
		Strongly Agree=5
	My need was addressed.	1=Strongly Disagree		Y	Radio button, scale, no don't know		A11-Quality
		2
		3
		4
		Strongly Agree=5
	It was easy to complete what I needed to do.	1=Strongly Disagree		Y	Radio button, scale, no don't know		A11-Ease
		2
		3
		4
		Strongly Agree=5
	It took a reasonable amount of time to do what I needed to do.	1=Strongly Disagree		Y	Radio button, scale, no don't know		A11-Speed
		2
		3
		4
		Strongly Agree=5
	I was treated fairly.	1=Strongly Disagree		Y	Radio button, scale, no don't know		A11-Treatment
		2
		3
		4
		Strongly Agree=5
	Employees I interacted with were helpful.	1=Strongly Disagree		Y	Radio button, scale, no don't know		A11-Helpful
		2
		3
		4
		Strongly Agree=5
	The office location is accessible and easy to locate.	1=Strongly Disagree		Y	Radio button, scale, no don't know		Accessible
		2
		3
		4
		Strongly Agree=5
	The office appearance was satisfactory.	1=Strongly Disagree		Y	Radio button, scale, no don't know		Appearance
		2
		3
		4
		Strongly Agree=5
	The office comfort was satisfactory.	1=Strongly Disagree		Y	Radio button, scale, no don't know		Comfort
		2
		3
		4
		Strongly Agree=5
	The signs and instructions explaining how to check-in were visible and easy to understand.	1=Strongly Disagree		Y	Radio button, scale, no don't know		Check-in
		2
		3
		4
		Strongly Agree=5
	The information located in the waiting area (posters, pamphlets, TV presentation) was helpful.	1=Strongly Disagree		Y	Radio button, scale, no don't know		Waiting
		2
		3
		4
		Strongly Agree=5
	I had no concerns about other people hearing my conversation with the SSA representative.	1=Strongly Disagree		Y	Radio button, scale, no don't know		Privacy
		2
		3
		4
		Strongly Agree=5
	The SSA representative who helped me was professional.	1=Strongly Disagree		Y	Radio button, scale, no don't know		Knowledgeable
		2
		3
		4
		Strongly Agree=5
	What was the main reason for your visit to this Social Security office?	Apply for Retirement/Survivor Benefits	A	Y	Radio button, one-up vertical	Skip Logic Group*	Primary Reason
		First-time Social Security Card
		Replacement/Update of my Social Security Card
		Discuss an update to SSA (change of address, report work activity, overpayment, etc.)
		Benefit verification letter	E
		Check the status of my pending claim	F
		Supplemental Security Income (SSI)
		Apply for Disability Benefits	B
		Medicare	C
		Other, please specify	D
D	Please specify the main reason for your visit.			N	Text field, <100 char	Skip Logic Group*	Primary Reason Other
A	Were you aware that you can apply for retirement benefits online at ssa.gov?	Yes	A1	Y	Radio button, one-up vertical	Skip Logic Group*	Online Aware Apply
		No
A1	Why did you choose to visit a Social Security office instead of applying online?			N	Text area, no char limit	Skip Logic Group*	Why Not Apply Online
B	Were you aware that you can apply for Disability Benefits online at ssa.gov?	Yes	B1	Y	Radio button, one-up vertical	Skip Logic Group*	Online Aware B
		No
B1	Why did you choose to visit a Social Security office instead of applying for Disability Benefits online?			N	Text area, no char limit	Skip Logic Group*	OE_Online Aware B
C	Were you aware that you can apply for Medicare online at ssa.gov?	Yes	C1	Y	Radio button, one-up vertical	Skip Logic Group*	Online Aware C
		No
C1	Why did you choose to visit a Social Security office instead of applying for Medicare online?			N	Text area, no char limit	Skip Logic Group*	OE_Online Aware C
E	Were you aware that you can view or print your benefit verification letter online at ssa.gov?	Yes	E1	Y	Radio button, one-up vertical	Skip Logic Group*	Online Aware Letter
		No
E1	Why did you choose to visit a Social Security office instead of viewing or printing your benefit verification letter online?			N	Text area, no char limit	Skip Logic Group*	OE_Online Aware Letter
F	Were you aware that you can check the status of a pending claim online at ssa.gov?	Yes	F1	Y	Radio button, one-up vertical	Skip Logic Group*	Online Aware Status
		No
F1	Why did you choose to visit a Social Security office instead of checking the status of an existing claim online?			N	Text area, no char limit	Skip Logic Group*	OE_Online Aware Status
	Were you able to accomplish what you needed to during this office visit?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Accomplish
		No	A, B
A	Why were you unable to accomplish what you needed to?				Text area, no char limit	Skip Logic Group*	Why Not Accomplish
B	What do you plan to do next in order to accomplish what you need to? (Please select all that apply.)	Visit this Social Security office again at a later date		Y	Checkbox, one-up vertical	Skip Logic Group*	Do Next Not Accomplish
		Visit a different Social Security office
		Call the Social Security National 800 number
		Visit the Social Security website
		Other, please specify	B1
		Not sure				Mutually Exclusive
B1	Please specify what you plan to do next.			N	Text area, no char limit	Skip Logic Group*	Do Next Other
	Did you do any of the following before your visit to this Social Security office to try and accomplish what you needed to?	Yes, I had made a prior visit to this Social Security office		Y	Checkbox, one-up vertical		Prior Attempt
		Yes, I made a visit to another Social Security office
		Yes, I called the National 800 number
		Yes, I visited the website
		No				Mutually Exclusive
	Did you visit the Social Security office in Westchester, PA?	Yes	A	Y	Radio button, one-up vertical	Skip Logic Group*	Westchester Pilot
		No
A	Did you visit Social Security for yourself or on behalf of someone else?	Myself		Y	Radio button, one-up vertical	Skip Logic Group*	Westchester Pilot_On Behalf
		Someone else (e.g., child, parent, client)
		Representative Payee or Payee Organization
		Other
A	Did you have an appointment?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Westchester Pilot_Appointment
		No
A	How did you interact with a Social Security Representative today? (select all that apply)	At an interviewing window		Y	Checkbox, one-up vertical	Skip Logic Group*	Westchester Pilot_Rep Interact
		At the Innovation Lab assistance window
		On a videophone in the Innovation Lab
		I did not interact with a Social Security Representative today				Mutually Exclusive
A	What device(s) did you use today? (select all that apply)	Smart Tablet	B	Y	Checkbox, one-up vertical	Skip Logic Group*	Westchester Pilot_Device
		Express services computer desk station	C
		Self-Service Technology Center (Benefit verification letter, benefit estimate)	D
		Information Center	E
		Megan (Hologram)	F
		I did not use any of the devices listed above				Mutually Exclusive
B	Were you satisfied with the Smart Tablet experience?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Westchester Pilot_Smart Tablet
		No	B1
B1	Why were you dissatisfied with the Smart Tablet experience?			N	Text area, no char limit	Skip Logic Group*	OE_Westchester Pilot_Smart Tablet
C	Were you satisfied with the Express services computer desk station?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Westchester Pilot_Express Services
		No	C1
C1	Why were you dissatisfied with the Express services computer desk station?			N	Text area, no char limit	Skip Logic Group*	OE_Westchester Pilot_Express Services
D	Were you satisfied with the Self-Service Technology Center?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Westchester Pilot_Self Serve
		No	D1
D1	Why were you dissatisfied with the Self-Service Technology Center?			N	Text area, no char limit	Skip Logic Group*	OE_Westchester Pilot_Self Serve
E	Were you satisfied with the Information Center?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Westchester Pilot_Info Center
		No	E1
E1	Why were you dissatisfied with the Information Center?			N	Text area, no char limit	Skip Logic Group*	OE_Westchester Pilot_Info Center
F	Were you satisfied with our hologram unit Megan?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Westchester Pilot_Hologram
		No	F1
F1	Why were you dissatisfied with our hologram unit Megan?			N	Text area, no char limit	Skip Logic Group*	OE_Westchester Pilot_Hologram
A	Are you likely to use Social Security’s Self-Service tools in the future?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Westchester Pilot_Tools
		No	M
M	Why aren't you likely to use the Self-Service tools?			N	Text area, no char limit	Skip Logic Group*	OE_Westchester Pilot_Tools Future Use
A	Will you recommend Social Security’s Self-Service tools to someone else?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Westchester Pilot_Recommend
		No	N
N	Why Not?			N	Text area, no char limit	Skip Logic Group*	OE_Westchester Pilot_Recommend
A	Thinking about your reason for visiting today, would you be comfortable doing the same business:	Over the phone		Y	Checkbox, one-up vertical	Skip Logic Group*	Westchester Pilot_Other Channels
		On the internet
		Neither, I want to do this type of business in person				Mutually Exclusive
A	Do you have a mySocialSecurity account?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Westchester Pilot_mySS Account
		No
A	Highest education completed:	Elementary school		N	Radio button, one-up vertical	Skip Logic Group*	Westchester Pilot_Demo Education
		High school
		College
		Advanced degree(s)
		Prefer not to say
	Did you visit the Chicago Loop Social Security office on Washington Blvd.?	Yes	A	Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot
		No
A	Why did you visit Social Security today?	Retirement		Y	Checkbox, one-up vertical	Skip Logic Group*	Chicago Pilot_Reason
		Disability
		Replace Social Security Card	Z
		Medicare
		Supplemental Security Income (SSI)
		New Social Security Card	Z
		Other
Z	Were you satisfied with the orange interview station that you used to complete your Social Security card application?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Orange Station
		No
		Does not apply
Z	Were you satisfied with the grey interview station that you used to complete your Social Security card application?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Grey SSA Card
		No
		Does not apply
Z	Did you find the informational video about the Social Security card application (new, replacement, name change) useful when checking in?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Informational Video
		No
A	Did you visit Social Security for yourself or on behalf of someone else?	Myself		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_On Behalf
		Someone else (e.g., child, parent, client)
		Representative Payee or Payee Organization
		Other
A	Did you have an appointment?	Yes	B	Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Appointment
		No
B	Did you receive a barcoded Appointment Xpress letter?	Yes	C	Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Barcode Xpress
		No
C	Would you prefer to receive the Appointment Xpress letter by  email or other electronic format?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Letter Xpress
		No
C	Were you satisfied with the Appointment Xpress check-in kiosk and instructions?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Xpress Appointment
		No
		I did not use it	D
D	Why not?	Forgot my letter		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Xpress Appointment Didnt Use
		Kiosk didn't work
		Didn't see the kiosk
		Didn't understand what to do
		Other
C	Did you find the pictures and instructions on the back of the Appointment Xpress letter helpful?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Xpress Pictures
		No
C	Were you satisfied with the QR code and check-in process?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_QR Code
		No
		I have no idea what a QR code is or how to use one
C	Did you use the iCalendar feature to remind you of your appointment?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_iCalendar
		No
C	Were you satisfied with the video instructions from “Toni ” in the entryway?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Toni
		No
C	Did having the large screen monitor by the door help you to check-in with Appointment Xpress?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Monitor
		No
A	Would you like the option to check in by your smart phone?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Smart Phone
		No
A	Please check all the ways you interacted with Social Security today. (select all that apply)	Worked/talked with a Social Security Rep		Y	Checkbox, one-up vertical	Skip Logic Group*	Chicago Pilot_Interact
		On a self-service computer	E,G
		On a video call	E
		At an interviewing window
		On a tablet
		Using Live Chat
		Other
E	Were you satisfied with the sound quality of your video interview?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Sound Quality
		No
G	Please select why you chose Self-Help. (select all that apply)	Someone sent me to Self-Help		Y	Checkbox, one-up vertical	Skip Logic Group*	Chicago Pilot_Self Help
		I prefer Self-Help				Randomize
		I saw a Self-Help video
		The wait was shorter
		I like to try new things
		I followed the footsteps
		Other	J			Anchor Answer Choice
J	Please specify the reason you chose Self-Help.			N	Text area, no char limit	Skip Logic Group*	OE_Chicago Pilot_Self Help
G	Were you satisfied with today’s OVERALL Self-Help electronic services experience?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Overall Self Help
		No
G	Are you likely to use Social Security’s Self-Help tools in the future?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Self Help Tools
		No
A	Were you satisfied with your ability to hear the Social Security representative in the office?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Hear Rep
		No	A1
A1	Did the representative offer you a headset?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Headset
		No
		Does not apply
A	Did you find the informational videos playing in the waiting area helpful?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Vidoes Helpful
		No
A	Did the videos encourage you to use the Self-Help/Self-Service options or conduct your business online?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Conduct Online
		No
A	Did you use the tablet in the waiting area to visit SSA.gov?	Yes	K	Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Tablet
		No
K	Please select all the business you attempted to complete on the tablet.	Replacemt Social SecurityCard		Y	Checkbox, one-up vertical	Skip Logic Group*	Chicago Pilot_Tablet Businesses
		Replacement Medicare Card
		Estimate Your Retirement Benefits
		Create a mySocialSecurity Account
		Change Your Address or Direct Deposit
		Benefit Verification Letter
		Other	L
L	Please specify what business you attempted to complete on the tablet.			N	Text area, no char limit	Skip Logic Group*	OE_Chicago Pilot_Tablet Businesses
A	Were you satisfied with the table mounted tablet interview station that you used to complete my Social Security card application?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	OE_Chicago Pilot_Tablet SSA Card
		No
		Does not apply
A	Did completing the Social Security card application at the interview station prior to your interview help you once you were called?	Yes		Y	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_SSA Card Help
		No
A	Thinking about your reason for visiting today, would you be comfortable doing the same business:	Over the phone		Y	Checkbox, one-up vertical	Skip Logic Group*	Chicago Pilot_Comfort Elsewhere
		On the internet
		Neither. I want to do this type of business in person.				Mutually Exclusive
A	Please provide any additional comments.			N	Text area, no char limit	Skip Logic Group*	OE_Chicago Pilot_Additional Comments
A	Highest education completed:	Elementary school		N	Radio button, one-up vertical	Skip Logic Group*	Chicago Pilot_Demo Education
		High school
		College
		Advanced degree(s)
		Prefer not to say