Form T-36 (Propose Form T-36 (Propose Customer Experience Survey

Form Approved
OMB No. 3220-0192

Customer-driven Quality
Service Is Our Top Priority
Dear Customer:
Our goal is to provide you the efficient,
friendly service you deserve. Please take a
moment to tell us how our agency served you
in your recent call.
If our agency did not meet your expectations,
we want to hear about it. Likewise, if you
received EXCELLENT customer service, we
want to hear that too so that we can commend
our employees for a job well done.
Your comments and suggestions allow us to
improve our level of service. Our top priority
is you, the customer. We want to make sure
you are pleased with the service you receive.

Working to Strengthen
America’s
Commitment to
Quality

Customer
Experience
Survey

Sincerely,
Erhard R. Chorle’
Chairman
John Bragg
Labor Member
Thomas R. Jayne
Management Member

United States of America
Railroad Retirement Board
Visit our Web site at www.rrb.gov
T-36 (XX-XX)

Your opinions are very important to us! Please complete
this quick customer satisfaction survey so that we will be
better able to evaluate and improve our level of customer
service.

4.

Date of your call:__________________
Time of your call:__________________
Please rate the following items by placing a check mark on
the line that best describes your experience.
1.

2.

3.

How would you rate your overall customer
experience?
___ Very satisfied
___ Moderately satisfied
___ Neither satisfied or dissatisfied
___ Moderately dissatisfied
___ Very dissatisfied
How satisfied are you with how quickly your call was
answered by a representative?
___ Very satisfied
___ Moderately satisfied
___ Neither satisfied or dissatisfied
___ Moderately dissatisfied
___ Very dissatisfied
Upon contacting the agency, your call was answered:
___ Within 10 minutes
___ Between 10 to 30 minutes
___ Over 30 minutes
___ My call was not answered or I abandoned the
call.

Paperwork Reduction Act and Privacy Act Notices

.

5.

6.

7.

How satisfied are you with your representative’s
knowledge and expertise in assisting you?
___ Very satisfied
___ Moderately satisfied
___ Neither satisfied or dissatisfied
___ Moderately dissatisfied
___ Very dissatisfied
How satisfied are you with the representative’s level
of courtesy and politeness?
___ Very satisfied
___ Moderately satisfied
___ Neither satisfied or dissatisfied
___ Moderately dissatisfied
___ Very dissatisfied
The purpose of your call was:
___ Unemployment benefits
___ Sickness benefits
___ Retirement benefits
___ Survivor benefits
___ Disability benefits
___ Medicare application
___ Other (specify) ____________________
Did you receive the information/service you were
seeking?
_____ Yes
_____ No (specify)

The Railroad Retirement Board (RRB) is authorized to collect the information requested on this
form under Section 7b(6) of the Railroad Retirement Act (RRA) and Section 5(b) of the Railroad
Unemployment Insurance Act (RUIA). The information is needed so that the RRB can determine
your opinion as to the quality of its service to you with respect to your application or claim for
RRA/RUIA benefits and general inquires you may have made with the RRB. Although you are
not required to provide the requested information, your cooperation in doing so will assist the
RRB in its continuing efforts to provide the public with timely and high quality service.

_______________
_______________

8.

Are there any additional comments you wish to share
about your contact with our agency?
____________________________________________
____________________________________________
____________________________________________
____________________________________________

9.

Are there any suggestions on how we could improve
our level of service?
____________________________________________
____________________________________________
____________________________________________
____________________________________________

OPTIONAL
Name: __________________________________________
Address: ________________________________________
________________________________________
Phone: __(

)_______________________________

Simply fold, tape and drop in any mailbox. This
survey has been postage paid for your
convenience.

_______________

We estimate this form takes an average of 2 minutes per response to complete, including the
time required for reviewing the instructions, getting the needed data, and reviewing the
completed form. Federal agencies may not conduct or sponsor, and respondents are not
required to respond to, a collection of information unless it displays a valid OMB number. If
you wish, send comments regarding the accuracy of our time estimate for this form, including
suggestions for reducing completion time, to Associate Chief Information Officer for Policy and
Compliance, Railroad Retirement Board, 855 North Rush Street, Chicago, IL 60611-1275.