Form FEMA Form FF-104-F FEMA Form FF-104-F Transitional Shelter Assistance Survey- Electronic

T RANSITIONAL SHELTERING ASSISTANCE (TSA) Survey- Electronic

FEMA LOGO (TOP LEFT FIRST PAGE ONLY)

OMB Control Number 1660-0145

Expiration: xx/xx/xxxx

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, except as allowed under the routine uses published in System of Records Notice DHS/FEMA-008 - Disaster Recovery Assistance Files, 78 FR 25282 (April 30, 2013), or as required by law. The Department's system of records notices can be found on the Department's website at http://www.dhs.gov/system-records-notices-sorns.

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. Questions regarding this form may be submitted via email to [email protected].

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Begin Survey

(Note for CSA-the below will be reformatted to include required screen/page breaks prior to loading into software).

INFORMATION

Using a rating scale of 1 (Poor) to 5 (Excellent), how would you rate the Transitional Sheltering Assistance (TSA) Program information provided by FEMA on…

	1 Poor	2	3	4	5 Excellent	No Information received
1. Being easy to understand	O	O	O	O	O	O
2. Answering your questions	O	O	O	O	O	O
3. Being helpful	O	O	O	O	O	O
4. Explaining what happens next	O	O	O	O	O	O
5. Overall satisfaction with information	O	O	O	O	O	O

FEMA used multiple methods to communicate Transition Sheltering Information. Using a scale of 1 (Not at all Effective) to 5 (Very Effective) or Not Applicable, how would you rate communications by…

	1 Not at Effective	2	3	4	5 Very Effective	Not Applicable
6. E-mail	O	O	O	O	O	O
7. Text message	O	O	O	O	O	O
8. Phone call or message received from FEMA	O	O	O	O	O	O
9. Phone call you made to FEMA’s helpline	O	O	O	O	O	O
10. DisasterAssistance.gov website	O	O	O	O	O	O
11. TSA Hotel Locator List	O	O	O	O	O	O

CUSTOMER SERVICE

Using a scale of 1 (Poor) to 5 (Excellent) how would you rate FEMA representatives on…

	1 Poor	2	3	4	5 Excellent	Did not talk to FEMA Representative
12. Courtesy	O	O	O	O	O	O
13. Showing interest in helping	O	O	O	O	O	O
14. Overall customer service	O	O	O	O	O	O

ACCOMMODATIONS

Please use a scale of 1 (Not at all Satisfied) to 5 (Very Satisfied) or Not Applicable, how would you rate the Transitional Sheltering property you selected on the following:

	1 Not at all Satisfied	2	3	4	5 Very Satisfied	Not Applicable
15. Ease in finding a TSA participating lodging property with room availability	O	O	O	O	O	O
16. Accessibility for household members with disabilities and/or access functional needs	O	O	O	O	O	O
17. Conveniently located	O	O	O	O	O	O
18. Access to public transportation	O	O	O	O	O	O
19. Access to food services	O	O	O	O	O	O
20. Clean and well-maintained	O	O	O	O	O	O
21. Accepting household pets	O	O	O	O	O	O
22. Overall satisfaction with the accommodations	O	O	O	O	O	O

OVERALL TRANSITIONAL SHELTERING EXPERIENCE

Thinking about your overall Transitional Sheltering experience and using a scale of 1 (Poor) to 5 (Excellent), how would you rate FEMA on:

	1 Poor	2	3	4	5 Excellent
23. Making it easy to know your eligibility status	O	O	O	O	O
24. Timeliness of extension eligibility or ineligibility notifications	O	O	O	O	O
25. Helping to meet sheltering needs caused by the disaster	O	O	O	O	O

26. What suggestions do you have for improving FEMA’s Transitional Sheltering Assistance? (500 Character Maximum)

Demographics

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

◘ Yes

◘ No

(Programmer Note: If Q27 response = Yes go to 28 else go to Q37)

Q28. Is your gender…

◘ Female

◘ Male

◘ Other (e.g., transgender, nonbinary, or gender variant)

◘ Prefer not to answer

Q29. 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

Q30. Is your marital status…

◘ Never married

◘ Married or living with partner

◘ Separated

◘ Widowed

◘ Divorced

◘ Prefer not to answer

Q31. Is your current employment status…

◘ Employed for wages

◘ Self-employed

◘ Unemployed

◘ Homemaker

◘ Student

◘ Retired

◘ Prefer not to answer

Q32. 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

Q33. Are You Hispanic or Latino? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)

◘ Yes

◘ No

Q34. Please select the racial category or categories that you most closely identify with. Select as many as apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

• Prefer not to answer

Q35. 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 Q35 response = Yes go to Q36, else go to Q37)

Q36. 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

Q37. Your opinion is very valuable to us. May we contact you later to ask additional questions?

◘ Yes

◘ No

Close

Thank you for your time.

FEMA Form FF-104-FY-21-183 (formerly 519-0-47)