Brief Survey

OMB No. 0960-0229

2009 Survey Questions

1. Did any organization or company refer you to SSA to file for disability benefits? (Yes/No)

What type of organization referred you:

• Private disability company

• Public (state/local) disability program

• Worker’s compensation agency

• Department of Veteran’s Affairs

• State/local public assistance office (TANF, food stamps, general assistance programs)

• Unemployment office

• Other (please specify):

2. If yes, were you required to file for Social Security disability benefits as a condition of receiving cash benefits from the referring organization?

• Yes

• No

• Do not receive or expect to receive cash benefits from the organization that referred me.