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

A ssessment Survey-Electronic

OMB Control Number 1660-0143

Expiration: XXX XX, 20XX

PAPERWORK BURDEN DISCLOSURE NOTICE: Public reporting burden for this data collection is estimated to average 12 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 this form. This collection of information is voluntary. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. 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 20472-3100, Paperwork Reduction Project (1660-0143) 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. Summary and/or aggregate survey results and analysis may be shared with Congress and the Government Accountability Office; however, no Personally Identifiable Information (PII) will be shared externally. For more information on how DHS may share this data, please see DHS/FEMA/PIA-035 Customer Satisfaction Analysis System (CSAS), available at https://www.dhs.gov/privacy.

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.

Introduction – Electronic Survey (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 1660-0413. Your answers will not affect the outcome of your application for FEMA assistance.

Please click Next to begin the survey

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

INFORMATION & COMMUNICATIONS

1. Which one of the following was your main source for 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 Q9)

Using a scale of 1 (Poor) to 5 (Excellent), please rate the [Q1 response] information on…

	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. Providing information in your preferred language	◘	◘	◘	◘	◘
7. Timeliness	◘	◘	◘	◘	◘
8. Overall satisfaction with the information	◘	◘	◘	◘	◘

Please use a scale of 1 (Poor) to 5 (Excellent) or say No Experience if a question does not apply to you. How would you rate correspondence or other material you received from FEMA on…

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

(Programmer Note: If HA and/or ONA = Y go to Q16, If HA and ONA = N go to Q20)

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 scale of 1 (Poor) to 5 (Excellent). How would you rate FEMA financial assistance in…

	1 Poor	2	3	4	5 Excellent
16. Arriving in a reasonable amount of time	◘	◘	◘	◘	◘
17. Being an important part of your recovery	◘	◘	◘	◘	◘
18. Helping meet your disaster related needs	◘	◘	◘	◘	◘

(Programmer Note: If Q18 response = 1 or 2 go to Q19, if Q18 response = 3, 4, 5 or is null go to Q21)

19. 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

20.Which one of the following best describes why your disaster related needs for [Q19 Response] were not met?

◘ Not all damages were eligible for FEMA assistance

◘ Amount of FEMA financial assistance was too little

◘ Repair or replacement costs were too high

◘ Rental assistance was not enough

◘ Not all personal property was eligible for FEMA assistance

◘ Insurance settlement is pending

◘ FEMA appeal is pending

Using a scale of 1 (Not at all Recovered to 5 (Completely Recovered)…

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

(Programmer Note: If Q21 response = 1, 2 or 3 go to Q22, if Q21 response = 4 or 5 and inspection date is not null got to Q32 or if Q21 response = 4 or 5 and inspection date is null go to Q35, if Q21 response is null go to Q35)

Please think about the causes for delays in your recovery. As I read a list of possible causes for delays say Yes if that is cause, No if it is not, or No Experience if a question does not apply to you.

	Yes	No	No Experience
22. Money for home repairs	◘	◘	◘
23. Money for personal property	◘	◘	◘
24. Money to move to a new residence	◘	◘	◘
25. Delayed or denied insurance settlement	◘	◘	◘
26. Delayed FEMA appeal	◘	◘	◘
27. Lack of affordable and accessible housing	◘	◘	◘
28. Lack of time to make repairs	◘	◘	◘
29. Lack of contractors and or materials	◘	◘	◘
30. Medical or disability condition	◘	◘	◘
31. Unemployed as a result of the disaster	◘	◘	◘

(Programmer Note: If inspection date is not null go to Q32, if inspection date is null go to Q36)

INSPECTION

FEMA conducted your inspection on [Inspection Date]. Please use a rating scale of 1(Not at all Satisfied) to 5 (Very Satisfied). How satisfied were you with the…

	1 Not at all Satisfied	2	3	4	5 Very Satisfied
32. Timeliness of the inspection	◘	◘	◘	◘	◘
33. Professionalism of the inspector	◘	◘	◘	◘	◘
34. Helpfulness of the inspector	◘	◘	◘	◘	◘
35. Overall inspection experience	◘	◘	◘	◘	◘

CUSTOMER SERVICE & EXPECTATIONS

Based on your overall experience with FEMA and using a scale of 1 (Poor) to 5 (Excellent), how would you rate FEMA on providing…

	1 Poor	2	3	4	5 Excellent
36. Caring customer service	◘	◘	◘	◘	◘
37. Easy access to services	◘	◘	◘	◘	◘
38. Easy to understand information	◘	◘	◘	◘	◘
39. Information that was helpful in your recovery	◘	◘	◘	◘	◘
40. Timely information	◘	◘	◘	◘	◘
41. Information in your preferred language	◘	◘	◘	◘	◘
42. And on meeting your expectations	◘	◘	◘	◘	◘

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

◘ Internet

◘ In Person

◘ By Telephone

DEMOGRAPHICS

44. We’re almost done. Would you volunteer to answer a few demographic questions for statistical purposes?

◘ Yes

◘ No

(Programmer Note: If Q44 response = Yes go to Q45 else go to Q53)

45. What gender do you identify as?

◘ Female

◘ Male

◘ Prefer not to answer

46. 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

47. Is your marital status…

◘ Single

◘ Married

◘ Separated

◘ Widowed

◘ Divorced

◘ Prefer not to answer

48. Is your current employment status…

◘ Employed for wages

◘ Self-employed

◘ Unemployed

◘ Homemaker

◘ Student

◘ Retired

◘ Prefer not to answer

49. 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

50. 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

• ◘ Prefer not to answer

51. Do you or anyone in your household have a disability that affects your ability to carry out activities of daily living or requires an assistive device such as, but not limited to, a wheelchair, walker, cane, hearing aid, communication device, service animal, personal care attendant, oxygen or other similar medically-related devices or services?

◘ Yes

◘ No

(Programmer Note: If Q51 response = Yes go to Q52 else go to Q53)

52. Are the devices or services used to assist with any of the following? (You may select all that apply.)

• Mobility

• Cognitive, Developmental Disabilities, Mental Health

• Hearing and/or Speech

• Vision

• Self-Care

• Independent Living

• Other

53. Your opinion is very valuable to us. May we contact you later to ask additional questions?

◘ Yes

◘ No

Closing -

Thank you for your time.