FEMA Form 519-0-50 Shelter and Temporary Essential Power Survey- Phone

S HELTERING TEMPORARY ESSENTIAL POWER (STEP) SURVEY-Phone

OMB Control Number PROGNEW

Expiration XXX

PAPERWORK BURDEN DISCLOSURE NOTICE

FEMA Form 519-0-50 (Sheltering Temporary Essential Power - Phone Survey)

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 (PROGNEW) 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 and will not be shared outside of DHS/FEMA, 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.

Introduction – Phone Survey (Applicants who requested US mail will be surveyed by telephone)

Hello, I’m calling from FEMA, the Federal Emergency Management Agency. My name is _____. May I please speak with [Applicant Name] or the person most familiar with their FEMA application?

If no: Thank you for your time and have a good day/evening.

If yes: FEMA is looking for ways to improve services offered through the [STEP] program, and your opinion is very important. Would you volunteer to take 10-13 minutes to answer some questions?

If no: What would be a better time to call back? Thank you for your time and have a good day/evening.

If yes: These questions comply with the Privacy Act of 1974 and have been approved by the Office of Management and Budget under number (New OMB Number). Your answers will not affect the outcome of any FEMA assistance. This call may be monitored and/or recorded for quality assurance.

Please click Next to begin the survey:

The [STEP] program, funded by FEMA and the State of [State], arranged for workers to come to your home and make essential repairs. The questions in this survey relate only to the essential repairs provided through the [STEP] program.

Program Information

1. Which one of the following was your primary source of information about the [STEP] program?

• Community group (club, church, school etc.)

• Disaster workers

• Flyers, signs, billboards, posters, etc.

• Newspaper

• Radio

• Television

• Word of mouth (like friends, family, neighbors, employer, landlord, etc.)

• Internet

• Social media

• None of the above

(Programmer Note: If Q1 response = Word of mouth (like friends, family, neighbors, employer, landlord, etc. or None of the Above go to Q7 else go to Q2)

Using a rating scale of 1 to 5 where 1 is Poor and 5 is Excellent, how would you rate the information provided by [Q1response] on the following:

	1 Poor	2	3	4	5 Excellent
2. Being easy to understand
3. Answering your questions
4. Providing helpful information
5. Explaining what happens next
6. Overall satisfaction with the information

7. Which one of the following best describes where you were staying just prior to the completion of the [STEP] repairs?

• Damaged residence

• Mass shelter

• Motel/Hotel paid for by FEMA

• Motel/Hotel paid for by myself

• Rented house or apartment

• Friends/Family

• Employer/place of work

• Car or other vehicle

• None of the above

8. Which of the following repair and service restoral types were provided to you by the [STEP] program? (Select all that apply)

• Power/Electricity

• Gas

• Water

• Home heating, cooling and/or hot water heaters

• Bathroom repairs

• Flooring and/or walls

• Windows and/or doors

• Roof

• Kitchen repairs and/or appliances

• Debris removed to curb

• Smoke/Carbon Monoxide Detectors

• Clean and sanitize

• Plumbing repairs

• Don’t know/Don’t remember

Programmer Note: (If Q8 response = Don’t know/Don’t remember go to Close)

[STEP] Program Satisfaction

Using a rating scale of 1 to 5 where 1 is Not at all Important and 5 is Very Important ….

	1 Not at all Important	2	3	4	5 Very Important
9. How important is it for you to be able to live at home while you recover or make permanent repairs?

10. Based on the information you received about the [STEP] program, how would you rate the repairs in meeting your expectations?

• Exceeded expectations

• Met expectations

• Failed to meet expectations

• Had no expectations

Please use a rating scale of 1 to 5 where 1 is Strongly Disagree and 5 is Strongly Agree. What is your level of agreement with the following statements about the [STEP] program?

	1 Strongly Disagree	2	3	4	5 Strongly Agree
11. The program allowed me to return or remain in my home.
12. The [STEP] repairs were made in a reasonable amount of time.
13. The [STEP] repairs made my home a safe place to stay.

Programmer Note: (If Q13 response = 1 or 2 go to Q13a else go to Q14)

13 a. What was the main reason the repairs did not make your home a safe place to stay?

• Not enough repairs

• Quality of work or materials

• Other disaster-related issues

• None of the above

Programmer Note: (If Q13a response Not enough repairs go to Q13b else go to Q14)

13b. Please list the repairs you feel were needed to make your home safe. (500 character maximum)

Using a rating scale of 1 to 5 where 1 is Not at all Satisfied and 5 is Very Satisfied…

	1 Not at all Satisfied	2	3	4	5 Very Satisfied
Overall, how satisfied were you with the [STEP] program?

15. What suggestions do you have for improving the [STEP] program? (500 character maximum)

Demographics

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

• Yes

• No

(Programmer Note: If Q16 response = Yes go to Q17 else go to Q25.)

16. Are there any children living in the recently repaired home under the age of 5?

• Yes

• No

• Prefer not to answer

(Programmer Note: If Q17response = Yes go to Q18 else go to Q19)

16. Is the age range of the youngest child…

• Less than 1

• 1 to 3

• 4 to 5

16. Is your gender…

• Female

• Male

• Prefer not to answer

16. 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

16. Is your marital status…

• Single

• Married

• Separated

• Widowed

• Divorced

• Prefer not to answer

16. Is your current employment status…

• Employed for wages

• Self-employed

• Unemployed

• Homemaker

• Student

• Retired

• Prefer not to answer

16. 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

16. Which of the following is your race or ethnic group: (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

16. Your opinion is very valuable to us. May we contact you at a later date to ask additional questions?

• Yes

• No

CLOSING Phone Survey

Thank you for your time. My name is _____ and my ID number is _______. Have a good day/evening.