OMB Approval Expiration Date
SSI/SSDI Initial Enrollment Survey
Introduction: Thank you for taking time to tell us about your experience working with our Medicaid Eligibility Specialist (and Forensic Peer Mentor, if applicable) to apply for Social Security Income and Social Security Disability Insurance benefits.
Participation is voluntary but very important. The survey takes about 18 minutes to complete. Your responses will be kept private and used only for research purposes. You may skip any question you do not wish to answer. All survey responses will be kept private.
We appreciate your feedback and hope to use your responses to improve services for you and others we work with.
SECTION 1
How would you rate your overall quality of life today?
Delighted
Pleased
Mostly Satisfied
Mixed
Mostly Dissatisfied
Unhappy
Terrible
Have you ever received SSI/SSDI benefits before?
Yes
No
I am not sure
Before working with the Medicaid Eligibility Specialist, had you ever been told you may qualify for benefits?
Yes
No
Can’t remember
SECTION 2
The next section asks you how you view your mental illness.
Rate how you feel about each statement below. |
Strongly Agree |
Agree |
Neither |
Disagree |
Strongly Disagree |
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SECTION 3
This next section asks you about your experience working with the Medicaid Eligibility Specialist (MES).
Describe your overall experience working with the Medicaid Eligibility Specialist (MES).
Great
OK
Poor
Rate how you feel about each statement below. |
Strongly Agree |
Agree |
Neither |
Disagree |
Strongly Disagree |
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Are you working with a Forensic Peer Mentor?
Yes
No
I am not sure
SECTION 4
The
next section asks about your experience with the Forensic
Peer Mentor (FPM).
[IF
YES TO 21.]
Describe your overall experience working with the Forensic Peer Mentor (FPM).
Great
OK
Poor
Rate how you feel about each statement below. |
Strongly Agree |
Agree |
Neither |
Disagree |
Strongly Disagree |
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How often does the FPM check in on you?
Daily
Weekly
Every other week
About once per month
I always initiate contact with the FPM
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | NaShandra Howard |
File Modified | 0000-00-00 |
File Created | 2023-11-14 |