Customer Satisfaction Survey - eServices Kiosks

You do not have to provide the information requested. However, the information you provide will help us evaluate and improve your kiosk experience in the future. Your individual answers are separate from your account activity and cannot affect your future benefits in any way. We estimate that it will take about 5 minutes to complete this survey. This includes the time it will take to read the questions and give your responses.

1. How did you use the SSA Express Kiosk today? (User can select more than one response)

• I was unable to complete an action

• I was just curious about the kiosk

• Created a My SSA Account

• Changed my address

• Changed/Started direct deposit

• Printed a Benefit Verification Letter

• Verified my benefit and payment information

• Verified my earnings record

• Estimated my retirement benefits

• Requested a replacement Medicare Card

• Printed a 1099/1042 Tax Form

• Other (Explain)____________

2. How do you rate your overall satisfaction with the SSA Express Kiosk?

• Excellent

• Above average

• Neutral

• Below average

• Poor

3. Do you foresee using the SSA Express Kiosk again?

• Yes

• No

• Maybe

4. Did you use the video assistance option today?

• Yes

• No

1. How would you rate the video assistance option?

• Excellent

• Above average

• Neutral

• Below average

• Poor

5. What other features would you like to see in a SSA Express Kiosk?

OMB Control No. 0960-0788

Expiration Date:  July 2014

Paperwork Reduction Act Statement

Paperwork Reduction Act Statement – This information collection meets the requirements of 44 U.S.C. §3507, as amended by section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions unless we display a valid Office of Management and Budget control number. We estimate that it will take about 5 minutes to complete this survey. You may send comments on our time estimate above: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address.

6. How do you usually conduct business with SSA?

• Visit a field office

• Call

• Use the Internet

• Other (Explain)

7. Which of the following benefits do you receive? (User can select more than one response)

• Retirement

• Disability

• Supplemental Security Income (SSI)

• I do not currently receive any benefits

• Other (explain)

8. What is your age?

• 18-24

• 25-34

• 35-44

• 45-54

• 55-64

• 65-74

• 75 or older