Appendix
A
SURVEY QUESTIONNAIRE WITH WITH THREE SCALES
HOW WELL IS SOCIAL SECURITY SERVING YOU?
The Office of the Inspector General has been asked
to look at how well the Social Security Administration is serving
the public. To do this we need your help. Please complete this questionnaire
and mail it back to us. We would like you to answer the questions
even if you are not receiving benefits.
This survey is completely voluntary. Your answers will
not affect your eligibility for Social Security or any other government
benefits and will be kept confidential.
If you have questions about this survey, you can call
us toll-free at 1-800-772-8246. If you have any questions about your
Social Security claim or benefits, call 1-800-772-1213.
Thank you for helping us.
PAPERWORK REDUCTION ACT STATEMENT
The Paperwork Reduction Act of 1995 requires
us to notify you that this information collection is in accordance
with the clearance requirements of section 3507 of the Paperwork
Reduction Act of 1995. We may not conduct or sponsor, and you are
not required to respond to, a collection of information unless it displays a valid OMB control number.
TIME IT TAKES TO COMPLETE THIS FORM: We estimate that
it will take you about 2 to 3 minutes to complete this survey. This
includes the time it will take to read the instructions, gather any necessary facts and fill out the form. If you have comments or suggestions
on this estimate,
write to the Social Security Administration, ATTN: Reports Clearance Officer,
1-A-21 Operations Building, Baltimore, MD 21235. Send only comments relating
to our "time
it takes" estimate to the office listed above. All requests for Social
Security cards and other claims-related information
should be sent to your local Social Security office, whose address is listed
undeer Social Security Administration in the U.S. Government section our your telephone directory.
PLEASE ANSWER THE QUESTIONS, DETACH THIS SIDE, & MAIL
THE OTHER HALF
Office of the Inspector General OMB No. 0960-0526
1. Did you visit a Social Security office in the
last 12 months?
¨ No--GO TO QUESTION 2
¨ Yes--IF YES; Were you satisfied with SSA`s
service during your last visit?
¨ No ¨ Yes
2. Did you call the Social Security 800 number in the last 12 months?
¨ No--GO TO QUESTION 3
¨ Yes -- IF YES; Were you satisfied with SSA`s
service during your last call?
¨ No ¨ Yes
3. Did you call a local Social Security office in the last 12 months?
¨ No-- GO TO QUESTION 4
¨ Yes-- IF YES; Were you satisfied with SSA`s
service during your last call?
¨ No ¨ Yes
4. Overall, how would you rate the service that Social Security has given
you? (_only one)
V5-¨ Very Good ¨ Good ¨ Fair ¨ Poor ¨ Very
Poor
E4-¨ Excellent ¨ Good ¨ Average ¨ Poor
E5-¨ Excellent ¨ Good ¨ Average ¨ Poor ¨ Very
Poor
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