Form FEMA Form 519-0-37 FEMA Form 519-0-37 Intital Survey-Electronic

I nitial 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 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 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.

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.

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Introduction – Electronic Survey (Applicants who 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 will take 3-5 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 1660-0143. Your answers will not affect the outcome of your application for FEMA assistance.

Please click Next to begin the survey:

INFORMATION

These questions are about information given to you when you applied for FEMA assistance. Using a rating scale of 1 (Poor) to 5 (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 like the Small Business Administration or American Red Cross	◘	◘	◘	◘	◘
4. Explaining what happens next	◘	◘	◘	◘	◘
5. Providing information in your preferred language	◘	◘	◘	◘	◘
6. Overall satisfaction with the information	◘	◘	◘	◘	◘

(Programmer note: If Type flag = Phone or DSAT go to Q7 if Internet go to Q12)

CUSTOMER SERVICE

Please use the same scale and rate the representative, who assisted with your application, on…

	1 Poor	2	3	4	5 Excellent
7. Courtesy	◘	◘	◘	◘	◘
8. Showing interest in helping	◘	◘	◘	◘	◘
9. And on overall customer service	◘	◘	◘	◘	◘

(Programmer Note: If Type Flag = DSAT go to Q16)

Using a rating scale of 1 (Not at all Satisfied) to 5 (Very Satisfied), how satisfied were you with…

	1 Not at all Satisfied	2	3	4	5 Very Satisfied
10. The amount of time it took for a FEMA representative to answer your call?	◘	◘	◘	◘	◘

(Programmer Note: If Q10 response = 1 or 2 go to Q11, else go to Q16)

11. Would an acceptable amount of time, to wait for a FEMA representative to answer your call, be…?

◘ Less than 2 minutes

◘ 2 – 3 minutes

◘ 3 - 5 minutes

◘ 5 – 7 minutes

◘ More than 7 minutes

(Programmer Note: Go to Q16)

FEMA APPLICATION AT DISASTERASSISTANCE.GOV

Think back to when you applied for FEMA assistance online at the DisasterAssistance.gov website. Please use a scale of 1 (Not at all Easy) to 5 (Very Easy) or if you had no experience with that service say No Experience. How simple was…

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

Using a rating scale of 1 (Not at all Easy) to 5 (Very Easy)…

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

(Programmer Note: If Q16 response = 1 or 2 go to Q17 else go to Q18).

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

◘ Took too long to complete application

◘ Questions were not easy to understand

◘ Terminology was confusing

◘ Information requested was not easily available

◘ DisasterAssistance.gov website was slow or inaccessible

◘ Information on what to do next was not easy to understand

◘ Waiting for an available agent took too long

DISASTER RECOVERY CENTER

18. Have you recently visited a FEMA Disaster Recovery Center?

◘ Yes

◘ No

(Programmer Note: If Q18 response = Yes go to Q19 else go to Q31)

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

◘ Community group like club, church, school

◘ Disaster workers

◘ Flyers, signs, billboards, posters

◘ Newspaper, radio, television

◘ Word of mouth like friends, family, neighbors, employer, landlord

◘ FEMA website

◘ State or Local Government websites or notices

◘ Social media

For the next question please use a scale of 1 (Poor) to 5 (Excellent) or if you had no experience with that service say No Experience. How would you rate the Disaster Recovery Center on the following:

	1 Poor	2	3	4	5 Excellent	No Experience
20. Public awareness of the center	◘	◘	◘	◘	◘	◘
21. Location	◘	◘	◘	◘	◘	◘
22. Hours of operation	◘	◘	◘	◘	◘	◘
23. Easy to understand brochures and materials	◘	◘	◘	◘	◘	◘
24. Organization	◘	◘	◘	◘	◘	◘
25. Efficiency	◘	◘	◘	◘	◘	◘
26. Caring customer service	◘	◘	◘	◘	◘	◘
27. Assistance in your preferred language including American Sign Language.	◘	◘	◘	◘	◘	◘
28. Handicap accessible	◘	◘	◘	◘	◘	◘
29. Being helpful in your recovery	◘	◘	◘	◘	◘	◘
30. Overall satisfaction	◘	◘	◘	◘	◘	◘

DEMOGRAPHICS

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

purposes?

◘ Yes

◘ No

(Programmer Note: If Q31 response = Yes go to Q32, else go to Q40)

32. What gender do you identify as?

◘ Female

◘ Male

◘ Prefer not to answer

33. 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

34. Is your marital status…

◘ Single

◘ Married

◘ Separated

◘ Widowed

◘ Divorced

◘ Prefer not to answer

35. Is your current employment status…

◘ Employed for wages

◘ Self-employed

◘ Unemployed

◘ Homemaker

◘ Student

◘ Retired

◘ Prefer not to answer

36. Which 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

37. 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

38. 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 Q38 response = Yes go to Q39, else go to Q40)

39. 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

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

◘ Yes

◘ No

Closing –

Thank you for your time.