Category D Comment Card Questionnaire Sample

Generic Clearance of Customer Satisfaction Surveys

Category D Comment Card Questionnaire Sample

OMB: 0960-0526

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OUR COMMITMENT TO YOU


When you conduct business with us:


  • We will provide service through knowledgeable employees who will treat you with courtesy, dignity and respect every time you do business with us.

  • We will provide you with our best estimate of the time needed to complete your request and fully explain any delays.

  • We will clearly explain our decisions so you can understand why and how we made them and what to do if you disagree.

PRIVACY ACT

The Social Security Administration is authorized to collect the information on this comment card under Section 702 of Title VII of the Social Security Act. Your response to these questions is strictly voluntary. The information you provide will be used to help us improve the service that we give you.


Paperwork Reduction Act Statement - This information collection meets the requirements of 44 U.S. C. § 3507, as amended by section 2 of the Paperwork Reduction Act of 1995 You do not need to answer these questions unless we display a valid Office of Management control number. We estimate that it will take you about 5 minutes to read instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U.S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). You may send comments on our time estimate above to SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.


PLEASE FILL OUT AND MAIL



Social Security Administration Form Approved OMB No. 0960-0526


HOW DID YOU LIKE OUR VIDEO SERVICE?



DATE



LOCATION (City/State):



DID YOU VISIT TO:



Report a Change for Your Records

Apply for disability benefits

Request a benefit verification

File an appeal


Apply for retirement or survivors benefits

Apply for SSI benefits


Apply for a Social Security Card


Other (specify) _________________

Did you have an appointment?


Yes


No

How long did you wait to be served?


30 minutes or less


More than 30 minutes


Blacken the circle which corresponds closest to your feelings.



HOW SATISFIED WERE YOU WITH:



Very Satisfied




Very

Dissatisfied


The overall service you received

Convenience of using video service

The ease of using video service

The clarity of the communication

The privacy of the video site


If you used the Video Service at a site other than a Social Security office, did you like the location of the site? Yes/ No


If no, why not:

___________________________________________________________________________

___________________________________________________________________________


COMMENTS/SUGGESTIONS TO IMPROVE OUR VIDEO SERVICE







Name (Optional)


Telephone Number (Optional)


(Area Code)

Address (Optional)






Approved, OMB Number 0960-0526



To the Public We Serve:


The Social Security Administration is committed to high-quality service. Providing high-quality service is more than just a slogan to us. It is our commitment to find out what you want and then continually improve the ways we deliver service to meet your expectations.


You can help us to improve our video service by taking a few minutes to answer the questions on this customer comment card. Please answer these questions based on your own experience with Social Security.


Don't delay; your responses are very important. Please mail the completed postage-paid comment

card to us.


Thank you for your assistance.


Best regards,


Linda S. McMahon

Deputy Commissioner

Office of Operations


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleOUR COMMITMENT TO YOU
AuthorSyed Ashfaq
File Modified0000-00-00
File Created2022-05-01

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