Form 1075 2014 830 SSA Disability Report

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Overview

Disability v2 Model Qsts
Custom Qsts v2
Custom Qsts v2 (7-21-14)
Custom Qsts v2 (7-17-14)
CQs v2 (6-24-14)
Custom Qsts v2 (6-12-14)
Custom Qsts v2 (1-24)
Custom Qsts v2 (12-10)

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Sheet 1: Disability v2 Model Qsts

Model Instance Name:
SSADisability v2
MID:		451pZNUxEwhdwdY1JBg4EA4C
Partitioned No					Element rotation scheme has been added
FPI Included(Y/N)?
NOTE: All non-partitioned surveys will NOT be imputed and the elements will be rotated as a default unless otherwise specified and approved by Research.
Date:		6/12/2013
SSADisability v2
Model questions utilize the ACSI methodology to determine scores and impacts
		ELEMENTS (drivers of satisfaction)			CUSTOMER SATISFACTION			FUTURE BEHAVIORS	FPI
	MQ Label			MQ Label			MQ Label		Y?
		Site Information (1=Poor, 10=Excellent, Don't Know)			Satisfaction			Recommend (1=Very Unlikely, 10=Very Likely)
1	Site Information - Thoroughness	Please rate the thoroughness of information provided in this application.	14	Satisfaction - Overall	What is your overall satisfaction with this application? (1=Very Dissatisfied, 10=Very Satisfied)	17	Recommend	How likely are you to recommend this application to someone else?
2	SiteInformation - Understandable	Please rate how understandable this application’s information is.	15	Satisfaction - Expectations	How well does this application meet your expectations? (1=Falls Short, 10=Exceeds)			Use Other Online Services (1=Very Unlikely, 10=Very Likely)
3	SiteInformation - Answers	Please rate how well the application’s information provides answers to your questions.	16	Satisfaction - Ideal	How does this application compare to your idea of an ideal application? (1=Not Very Close, 10=Very Close)	18	Use Other Online Services	How likely are you to use other Social Security online services?
		Site Performance (1=Poor, 10=Excellent, Don't Know)
4	Site Performance - Consistency	Please rate how quickly pages load in this application.
5	Site Performance - Errors	Please rate the consistency of speed from page to page in this application.
6	leann.hartka: Need label	Please rate the ability to load pages without getting error messages in this application.
		Navigation (1=Poor, 10=Excellent, Don't Know)
7	Navigation - Organized	Please rate how well the application is organized.
8	Navigation - Options	Please rate the options available for navigating this application.
9	Navigation - Layout	Please rate how well the application layout helps you find what you are looking for.
10	Navigation - Clicks	Please rate the number of clicks to get where you want in this application.
		Plain Language (1=Poor, 10=Excellent, Don't Know)
11	Plain Language - Clear	Please rate the clarity of the wording in this application.
12	Plain Language - Understandable	Please rate how well you understand the wording in this application.
13	Plain Language - Concise	Please rate this application on its use of short, clear sentences.

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Sheet 2: Custom Qsts v2

Model Instance Name:			red & strike-through: DELETE
SSADisability v2			underlined & italicized: RE-ORDER
MID:	451pZNUxEwhdwdY1JBg4EA4C		pink: ADDITION
Date:	11/1/2010		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
SSADisability v2 CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip To	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Labels
CAS0047707		What type of benefits were you applying for?	Retirement		Dropdown (Select-one)	Single	Y	Skip Logic Group	Type of Benefits
			Medicare only
			Disability
			Both Retirement and Disability
			Spouse's
			Other
CAS0045268		Are you applying online for yourself or are you helping someone else?	Myself		Drop down select one	Single	Y		Applying for
			Helping a Spouse/Relative/Friend
			Professional Helping a Client
			Other
CAS0045269		How did you learn about this online application? (Select all that apply.)	Official Social Security website		Check boc vertical one up	Multi	Y	Skip Logic	Learn about App
			Online search engine or other website
			Social Security employee	A
			Social Security Statement
			Social Security publication
			Relative or friend
			Doctor, social worker, attorney, or other professional
			Traditional media (TV, radio, newspaper, etc.)
			Online social media (Facebook, Twitter, etc.)
			Other, please specify	B
CAS0045270	A	How did you make contact with a Social Security employee?	Visited a local Social Security office		Drop down select one	Single	Y	Skip Logic	How Contact SSA employee
			Called a local Social Security office
			Called the national 800 number
			Other, please specify	AA
CAS0045271	AA	Please describe how you made contact with a Social Security employee.						Skip Logic	OPS how Contact SSA Employee
CAS0045272	B	Please specify how you learned about this online application.			Text box, no char limit		N	Skip Logic	OPS_learned of app
CAS0045273		Did you use any of the following to prepare to apply online? (Select all that apply.)	I used the Disability Benefits Checklist	A	check box one up vertical	Multi	Y	Skip Logic	Prepare for App
			I used the Disability Starter Kit	B
			I watched the instructional video	C
			I used other information on the Social Security website to prepare	D
			I used another resource to prepare to apply online	E
			I did not use any resources to prepare to apply online
CAS0045274	A	How helpful did you find the Disability Benefits Checklist?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Statement
			Somewhat helpful
			Not at all helpful
CAS0045275	B	How helpful did you find the Disability Starter Kit?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate RE Tools
			Somewhat helpful
			Not at all helpful
CAS0045276	C	How helpful did you find the instructional video?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Video
			Somewhat helpful
			Not at all helpful
CAS0045277	D	How helpful did you find the other information on the Social Security website?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Other Info on Website
			Somewhat helpful
			Not at all helpful
CAS0045278	E	Please describe what other resource(s) you used to prepare to apply online?			Text field, no char limit		N	Skip Logic	OPS Prepare for App
CAS0047708		Did you start a new online application today or did you return to a saved application?	Started a new application		Drop down select one	Single	Y		App Status
			Returned to work on a saved application
CAS0047725		Did you complete and submit this online application today?	Yes		Drop down select one	Single	Y	Skip Logic	Complete App
			No, I plan to complete and submit later	A
			No, I do not plan to complete and submit the online application	A
CAS0047730	A	If you did not complete and submit this online application today, please tell us why.	Too many questions		check box one up vertical	Multi	Y	Skip Logic	Not Complete App
			Takes too long to fill out
			Too complicated to use without help
			Didn't have information I needed like names, addresses, or dates
			Didn't understand what questions meant/how to answer
			I wanted to use the Retirement Estimator to reconsider my retirement options
			I needed to view my Social Security Statement and/or verify that my earnings record is correct
			My disabling condition prevents me from working with a computer for long periods
			I had a limited amount of time/family demands that kept me from working on it for very long
			I had technical problems like an error message or a mistake I couldn't fix
			Other, please specify	AA
CAS0047731	AA	Please tell us why you did not complete and submit this application today.			Text field, no char limit		N	Skip Logic	OPS Why Not Complete today
CAS0047732		So far, how long have you worked on this online application?	Up to 30 minutes		Radio button select one		Y		Time Spent
			More than 30 minutes up to 1 hour
			More than 1 up to 2 hours
			More than 2 up to 3 hours
			More than 3 up to 4 hours
			More than 4 hours
CAS0047733		How many times did you work on this online application?	One Time		Radio button select one		Y		Number of times
			Two Times
			Three Times
			Four Times
			Five or More Times
CAS0047734		How easy was it for you to find this online application?	Very easy						Find App
			Somewhat easy
			Somewhat hard	A
			Very hard	A
CAS0047735	A	Please tell us why it was hard to find the online application. (Select all that apply.)	Could not find where to start a new online application		check box one up vertical	Multi	Y	Skip Logic	Why hard to find
			Not clear where to go to return to a previously saved application
			It was not clear to me where the links would lead
			Difficulty using a link on the Social Security website
			The information did not seem to be organized in a logical manner
			I used the search feature but the results didn’t seem to apply.
			I tried to use the FAQ's, but couldn't find the online application
			Other reason (please describe)	AA
CAS0047736	AA	Please explain the reason why it was hard for you to find the online application.			N		N	Skip Logic	OPS Hard to Find
CAS0047709		How did you arrive at this online application today?	Used the Online Services link on the Social Security homepage		Radio Button	Single	Y	Skip Logic	Arrive at App
			Followed a link from somewhere else on the Social Security website
			Used the search feature on the Social Security website
			Used an outside search engine (i.e. Google, Bing, yahoo etc.)
			Followed a link from medicare.gov
			Followed a link from another website
			Site was bookmarked
			Other, please specify	A
CAS0047686	A	Please describe how you arrived at this online application today			Text field, no char limit		N		OPS Arrive at app
CAS0045279		Why did you choose to apply online? (Select all that apply.)	I did not want to go to a local Social Security office		check box one up vertical	Multi	Y	Skip Logic	Why Online
			I did not want to apply over the phone
			I prefer to use online services as much as possible
			I learned about applying online while visiting Social Security's website
			A Social Security employee recommended that I apply online
			A friend or relative recommended that I apply online
			I knew that if I had a question or problem applying online, I could still get help from Social Security
			I am filing on behalf of another person
			Other, please specify	A
CAS0045253	A	Please specify why you choose to apply online			Text field, no char limit		N		OPS Why Online
CAS0060249		Would you describe yourself as a Wounded Warrior or a Veteran of the United States military?	Yes		Radio button, one-up vertical	Single	N		Wounded Warrior - Veteran Status
			No
CAS0045254		What is your current marital status?	Married		Radio button, one-up vertical	Single	N	OPS Group	Marital Status
			Separated
			Divorced
			Widowed
			Never married
			Prefer not to answer
			Other, please specify	A
CAS0045255	A	Other marital status			Text field, <100 char		N	OPS Group	OPS Marital Status
STE0059663		Have you registered for a my Social Security account?	Yes		Radio button, one-up vertical	Single	Y		Have mySSA Account
			No	A
HAR0061402	A	What is the main reason you have not registered for a my Social Security account?	I am unaware of what a my Social Security account is.		Radio button, one-up vertical	Single	Y	Skip Logic	Why Not Have mySSA Account
			I tried to register for a my Social Security account, but was unsuccessful.
			I am currently trying to register for a my Social Security account.
			I do not want a my Social Security account.
			Other (please specify):	AA
HAR0061422	AA	Please tell us why you have not registered for a my Social Security account.			Text field, no char limit	Single	N	Skip Logic	OPS_Why Not Have mySSA Account
CAS0047685		Do you have any suggestions for improving Social Security's online application?			Text Area – no character limit		N		OE_Improvement

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Sheet 3: Custom Qsts v2 (7-21-14)

Model Instance Name:			red & strike-through: DELETE
SSADisability v2			underlined & italicized: RE-ORDER
MID:	451pZNUxEwhdwdY1JBg4EA4C		pink: ADDITION
Date:	11/1/2010		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
SSADisability v2 CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip To	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Labels
CAS0047707		What type of benefits were you applying for?	Retirement		Dropdown (Select-one)	Single	Y	Skip Logic Group	Type of Benefits
			Medicare only
			Disability
			Both Retirement and Disability
			Spouse's
			Other
CAS0045268		Are you applying online for yourself or are you helping someone else?	Myself		Drop down select one	Single	Y		Applying for
			Helping a Spouse/Relative/Friend
			Professional Helping a Client
			Other
CAS0045269		How did you learn about this online application? (Select all that apply.)	Official Social Security website		Check boc vertical one up	Multi	Y	Skip Logic	Learn about App
			Online search engine or other website
			Social Security employee	A
			Social Security Statement
			Social Security publication
			Relative or friend
			Doctor, social worker, attorney, or other professional
			Traditional media (TV, radio, newspaper, etc.)
			Online social media (Facebook, Twitter, etc.)
			Other, please specify	B
CAS0045270	A	How did you make contact with a Social Security employee?	Visited a local Social Security office		Drop down select one	Single	Y	Skip Logic	How Contact SSA employee
			Called a local Social Security office
			Called the national 800 number
			Other, please specify	AA
CAS0045271	AA	Please describe how you made contact with a Social Security employee.						Skip Logic	OPS how Contact SSA Employee
CAS0045272	B	Please specify how you learned about this online application.			Text box, no char limit		N	Skip Logic	OPS_learned of app
CAS0045273		Did you use any of the following to prepare to apply online? (Select all that apply.)	I used the Disability Benefits Checklist	A	check box one up vertical	Multi	Y	Skip Logic	Prepare for App
			I used the Disability Starter Kit	B
			I watched the instructional video	C
			I used other information on the Social Security website to prepare	D
			I used another resource to prepare to apply online	E
			I did not use any resources to prepare to apply online
CAS0045274	A	How helpful did you find the Disability Benefits Checklist?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Statement
			Somewhat helpful
			Not at all helpful
CAS0045275	B	How helpful did you find the Disability Starter Kit?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate RE Tools
			Somewhat helpful
			Not at all helpful
CAS0045276	C	How helpful did you find the instructional video?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Video
			Somewhat helpful
			Not at all helpful
CAS0045277	D	How helpful did you find the other information on the Social Security website?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Other Info on Website
			Somewhat helpful
			Not at all helpful
CAS0045278	E	Please describe what other resource(s) you used to prepare to apply online?			Text field, no char limit		N	Skip Logic	OPS Prepare for App
CAS0047708		Did you start a new online application today or did you return to a saved application?	Started a new application		Drop down select one	Single	Y		App Status
			Returned to work on a saved application
CAS0047725		Did you complete and submit this online application today?	Yes		Drop down select one	Single	Y	Skip Logic	Complete App
			No, I plan to complete and submit later	A
			No, I do not plan to complete and submit the online application	A
CAS0047730	A	If you did not complete and submit this online application today, please tell us why.	Too many questions		check box one up vertical	Multi	Y	Skip Logic	Not Complete App
			Takes too long to fill out
			Too complicated to use without help
			Didn't have information I needed like names, addresses, or dates
			Didn't understand what questions meant/how to answer
			I wanted to use the Retirement Estimator to reconsider my retirement options
			I needed to view my Social Security Statement and/or verify that my earnings record is correct
			My disabling condition prevents me from working with a computer for long periods
			I had a limited amount of time/family demands that kept me from working on it for very long
			I had technical problems like an error message or a mistake I couldn't fix
			Other, please specify	AA
CAS0047731	AA	Please tell us why you did not complete and submit this application today.			Text field, no char limit		N	Skip Logic	OPS Why Not Complete today
CAS0047732		So far, how long have you worked on this online application?	Up to 30 minutes		Radio button select one		Y		Time Spent
			More than 30 minutes up to 1 hour
			More than 1 up to 2 hours
			More than 2 up to 3 hours
			More than 3 up to 4 hours
			More than 4 hours
CAS0047733		How many times did you work on this online application?	One Time		Radio button select one		Y		Number of times
			Two Times
			Three Times
			Four Times
			Five or More Times
CAS0047734		How easy was it for you to find this online application?	Very easy						Find App
			Somewhat easy
			Somewhat hard	A
			Very hard	A
CAS0047735	A	Please tell us why it was hard to find the online application. (Select all that apply.)	Could not find where to start a new online application		check box one up vertical	Multi	Y	Skip Logic	Why hard to find
			Not clear where to go to return to a previously saved application
			It was not clear to me where the links would lead
			Difficulty using a link on the Social Security website
			The information did not seem to be organized in a logical manner
			I used the search feature but the results didn’t seem to apply.
			I tried to use the FAQ's, but couldn't find the online application
			Other reason (please describe)	AA
CAS0047736	AA	Please explain the reason why it was hard for you to find the online application.			N		N	Skip Logic	OPS Hard to Find
CAS0047709		How did you arrive at this online application today?	Used the Online Services link on the Social Security homepage		Radio Button	Single	Y	Skip Logic	Arrive at App
			Followed a link from somewhere else on the Social Security website
			Used the search feature on the Social Security website
			Used an outside search engine (i.e. Google, Bing, yahoo etc.)
			Followed a link from medicare.gov
			Followed a link from another website
			Site was bookmarked
			Other, please specify	A
CAS0047686	A	Please describe how you arrived at this online application today			Text field, no char limit		N		OPS Arrive at app
CAS0045279		Why did you choose to apply online? (Select all that apply.)	I did not want to go to a local Social Security office		check box one up vertical	Multi	Y	Skip Logic	Why Online
			I did not want to apply over the phone
			I prefer to use online services as much as possible
			I learned about applying online while visiting Social Security's website
			A Social Security employee recommended that I apply online
			A friend or relative recommended that I apply online
			I knew that if I had a question or problem applying online, I could still get help from Social Security
			I am filing on behalf of another person
			Other, please specify	A
CAS0045253	A	Please specify why you choose to apply online			Text field, no char limit		N		OPS Why Online
CAS0060249		Would you describe yourself as a Wounded Warrior or a Veteran of the United States military?	Yes		Radio button, one-up vertical	Single	N		Wounded Warrior - Veteran Status
			No
CAS0045254		What is your current marital status?	Married		Radio button, one-up vertical	Single	N	OPS Group	Marital Status
			Separated
			Divorced
			Widowed
			Never married
			Prefer not to answer
			Other, please specify	A
CAS0045255	A	Other marital status			Text field, <100 char		N	OPS Group	OPS Marital Status
STE0059663		Have you registered for a my Social Security account?	Yes		Radio button, one-up vertical	Single	Y		Have mySSA Account
			No	A
HAR0061402	A	What is the main reason you have not registered for a my Social Security account?	I am unaware of what a my Social Security account is.		Radio button, one-up vertical	Single	Y	Skip Logic	Why Not Have mySSA Account
			I tried to register for a my Social Security account, but was unsuccessful.
			I am currently trying to register for a my Social Security account.
			I do not want a my Social Security account.
			Other (please specify):	AA
HAR0061422	AA	Please tell us why you have not registered for a my Social Security account.			Text field, no char limit	Single	N	Skip Logic	OPS_Why Not Have mySSA Account
CAS0047685		Do you have any suggestions for improving Social Security's online application?			Text Area – no character limit		N		OE_Improvement

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Sheet 4: Custom Qsts v2 (7-17-14)

Model Instance Name:			red & strike-through: DELETE
SSADisability v2			underlined & italicized: RE-ORDER
MID:	451pZNUxEwhdwdY1JBg4EA4C		pink: ADDITION
Date:	11/1/2010		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
SSADisability v2 CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip To	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Labels
CAS0047707		What type of benefits were you applying for?	Retirement		Dropdown (Select-one)	Single	Y	Skip Logic Group	Type of Benefits
			Medicare only
			Disability
			Both Retirement and Disability
			Spouse's
			Other
CAS0045268		Are you applying online for yourself or are you helping someone else?	Myself		Drop down select one	Single	Y		Applying for
			Helping a Spouse/Relative/Friend
			Professional Helping a Client
			Other
CAS0045269		How did you learn about this online application? (Select all that apply.)	Official Social Security website		Check boc vertical one up	Multi	Y	Skip Logic	Learn about App
			Online search engine or other website
			Social Security employee	A
			Social Security Statement
			Social Security publication
			Relative or friend
			Doctor, social worker, attorney, or other professional
			Traditional media (TV, radio, newspaper, etc.)
			Online social media (Facebook, Twitter, etc.)
			Other, please specify	B
CAS0045270	A	How did you make contact with a Social Security employee?	Visited a local Social Security office		Drop down select one	Single	Y	Skip Logic	How Contact SSA employee
			Called a local Social Security office
			Called the national 800 number
			Other, please specify	AA
CAS0045271	AA	Please describe how you made contact with a Social Security employee.						Skip Logic	OPS how Contact SSA Employee
CAS0045272	B	Please specify how you learned about this online application.			Text box, no char limit		N	Skip Logic	OPS_learned of app
CAS0045273		Did you use any of the following to prepare to apply online? (Select all that apply.)	I used the Disability Benefits Checklist	A	check box one up vertical	Multi	Y	Skip Logic	Prepare for App
			I used the Disability Starter Kit	B
			I watched the instructional video	C
			I used other information on the Social Security website to prepare	D
			I used another resource to prepare to apply online	E
			I did not use any resources to prepare to apply online
CAS0045274	A	How helpful did you find the Disability Benefits Checklist?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Statement
			Somewhat helpful
			Not at all helpful
CAS0045275	B	How helpful did you find the Disability Starter Kit?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate RE Tools
			Somewhat helpful
			Not at all helpful
CAS0045276	C	How helpful did you find the instructional video?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Video
			Somewhat helpful
			Not at all helpful
CAS0045277	D	How helpful did you find the other information on the Social Security website?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Other Info on Website
			Somewhat helpful
			Not at all helpful
CAS0045278	E	Please describe what other resource(s) you used to prepare to apply online?			Text field, no char limit		N	Skip Logic	OPS Prepare for App
CAS0047708		Did you start a new online application today or did you return to a saved application?	Started a new application		Drop down select one	Single	Y		App Status
			Returned to work on a saved application
CAS0047725		Did you complete and submit this online application today?	Yes		Drop down select one	Single	Y	Skip Logic	Complete App
			No, I plan to complete and submit later	A
			No, I do not plan to complete and submit the online application	A
CAS0047730	A	If you did not complete and submit this online application today, please tell us why.	Too many questions		check box one up vertical	Multi	Y	Skip Logic	Not Complete App
			Takes too long to fill out
			Too complicated to use without help
			Didn't have information I needed like names, addresses, or dates
			Didn't understand what questions meant/how to answer
			My disabling condition prevents me from working with a computer for long periods
			I had a limited amount of time/family demands that kept me from working on it for very long
			I had technical problems like an error message or a mistake I couldn't fix
			Other, please specify	AA
CAS0047731	AA	Please tell us why you did not complete and submit this application today.			Text field, no char limit		N	Skip Logic	OPS Why Not Complete today
CAS0047732		So far, how long have you worked on this online application?	Up to 30 minutes		Radio button select one		Y		Time Spent
			More than 30 minutes up to 1 hour
			More than 1 up to 2 hours
			More than 2 up to 3 hours
			More than 3 up to 4 hours
			More than 4 hours
CAS0047733		How many times did you work on this online application?	One Time		Radio button select one		Y		Number of times
			Two Times
			Three Times
			Four Times
			Five or More Times
CAS0047734		How easy was it for you to find this online application?	Very easy						Find App
			Somewhat easy
			Somewhat hard	A
			Very hard	A
CAS0047735	A	Please tell us why it was hard to find the online application. (Select all that apply.)	Could not find where to start a new online application		check box one up vertical	Multi	Y	Skip Logic	Why hard to find
			Not clear where to go to return to a previously saved application
			It was not clear to me where the links would lead
			Difficulty using a link on the Social Security website
			The information did not seem to be organized in a logical manner
			I used the search feature but the results didn’t seem to apply.
			I tried to use the FAQ's, but couldn't find the online application
			Other reason (please describe)	AA
CAS0047736	AA	Please explain the reason why it was hard for you to find the online application.			N		N	Skip Logic	OPS Hard to Find
CAS0047709		How did you arrive at this online application today?	Used the Online Services link on the Social Security homepage		Radio Button	Single	Y	Skip Logic	Arrive at App
			Followed a link from somewhere else on the Social Security website
			Used the search feature on the Social Security website
			Used an outside search engine (i.e. Google, Bing, yahoo etc.)
			Followed a link from medicare.gov
			Followed a link from another website
			Site was bookmarked
			Other, please specify	A
CAS0047686	A	Please describe how you arrived at this online application today			Text field, no char limit		N		OPS Arrive at app
CAS0045279		Why did you choose to apply online? (Select all that apply.)	I did not want to go to a local Social Security office		check box one up vertical	Multi	Y	Skip Logic	Why Online
			I did not want to apply over the phone
			I prefer to use online services as much as possible
			I learned about applying online while visiting Social Security's website
			A Social Security employee recommended that I apply online
			A friend or relative recommended that I apply online
			I knew that if I had a question or problem applying online, I could still get help from Social Security
			I am filing on behalf of another person
			Other, please specify	A
CAS0045253	A	Please specify why you choose to apply online			Text field, no char limit		N		OPS Why Online
CAS0060249		Would you describe yourself as a Wounded Warrior or a Veteran of the United States military?	Yes		Radio button, one-up vertical	Single	N		Wounded Warrior - Veteran Status
			No
CAS0045254		What is your current marital status?	Married		Radio button, one-up vertical	Single	N	OPS Group	Marital Status
			Separated
			Divorced
			Widowed
			Never married
			Prefer not to answer
			Other, please specify	A
CAS0045255	A	Other marital status			Text field, <100 char		N	OPS Group	OPS Marital Status
STE0059663		Have you registered for a my Social Security account?	Yes		Radio button, one-up vertical	Single	Y		Have mySSA Account
			No	A
	A	What is the main reason you have not registered for a my Social Security account?	I am unaware of what a my Social Security account is.		Radio button, one-up vertical	Single	Y	Skip Logic	Why Not Have mySSA Account
			I tried to register for a my Social Security account, but was unsuccessful.
			I am currently trying to register for a my Social Security account.
			I do not want a my Social Security account.
			Other (please specify):	AA
	AA	Please tell us why you have not registered for a my Social Security account.			Text field, no char limit	Single	N	Skip Logic	OPS_Why Not Have mySSA Account
CAS0047685		Do you have any suggestions for improving Social Security's online application?			Text Area – no character limit		N		OE_Improvement

---

Sheet 5: CQs v2 (6-24-14)

Model Instance Name:			red & strike-through: DELETE
SSADisability v2			underlined & italicized: RE-ORDER
MID:	451pZNUxEwhdwdY1JBg4EA4C		pink: ADDITION
Date:	11/1/2010		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
SSADisability v2 CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip To	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Labels
CAS0047707		What type of benefits were you applying for?	Retirement		Dropdown (Select-one)	Single	Y	Skip Logic Group	Type of Benefits
			Medicare only
			Disability
			Both Retirement and Disability
			Spouse's
			Other
CAS0045268		Are you applying online for yourself or are you helping someone else?	Myself		Drop down select one	Single	Y		Applying for
			Helping a Spouse/Relative/Friend
			Professional Helping a Client
			Other
CAS0045269		How did you learn about this online application? (Select all that apply.)	Official Social Security website		Check boc vertical one up	Multi	Y	Skip Logic	Learn about App
			Online search engine or other website
			Social Security employee	A
			Social Security Statement
			Social Security publication
			Relative or friend
			Doctor, social worker, attorney, or other professional
			Traditional media (TV, radio, newspaper, etc.)
			Online social media (Facebook, Twitter, etc.)
			Other, please specify	B
CAS0045270	A	How did you make contact with a Social Security employee?	Visited a local Social Security office		Drop down select one	Single	Y	Skip Logic	How Contact SSA employee
			Called a local Social Security office
			Called the national 800 number
			Other, please specify	AA
CAS0045271	AA	Please describe how you made contact with a Social Security employee.						Skip Logic	OPS how Contact SSA Employee
CAS0045272	B	Please specify how you learned about this online application.			Text box, no char limit		N	Skip Logic	OPS_learned of app
CAS0045273		Did you use any of the following to prepare to apply online? (Select all that apply.)	I used the Disability Benefits Checklist	A	check box one up vertical	Multi	Y	Skip Logic	Prepare for App
			I used the Disability Starter Kit	B
			I watched the instructional video	C
			I used other information on the Social Security website to prepare	D
			I used another resource to prepare to apply online	E
			I did not use any resources to prepare to apply online
CAS0045274	A	How helpful did you find the Disability Benefits Checklist?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Statement
			Somewhat helpful
			Not at all helpful
CAS0045275	B	How helpful did you find the Disability Starter Kit?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate RE Tools
			Somewhat helpful
			Not at all helpful
CAS0045276	C	How helpful did you find the instructional video?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Video
			Somewhat helpful
			Not at all helpful
CAS0045277	D	How helpful did you find the other information on the Social Security website?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Other Info on Website
			Somewhat helpful
			Not at all helpful
CAS0045278	E	Please describe what other resource(s) you used to prepare to apply online?			Text field, no char limit		N	Skip Logic	OPS Prepare for App
CAS0047708		Did you start a new online application today or did you return to a saved application?	Started a new application		Drop down select one	Single	Y		App Status
			Returned to work on a saved application
CAS0047725		Did you complete and submit this online application today?	Yes		Drop down select one	Single	Y	Skip Logic	Complete App
			No, I plan to complete and submit later	A
			No, I do not plan to complete and submit the online application	A
CAS0047730	A	If you did not complete and submit this online application today, please tell us why.	Too many questions		check box one up vertical	Multi	Y	Skip Logic	Not Complete App
			Takes too long to fill out
			Too complicated to use without help
			Didn't have information I needed like names, addresses, or dates
			Didn't understand what questions meant/how to answer
			My disabling condition prevents me from working with a computer for long periods
			I had a limited amount of time/family demands that kept me from working on it for very long
			I had technical problems like an error message or a mistake I couldn't fix
			Other, please specify	AA
CAS0047731	AA	Please tell us why you did not complete and submit this application today.			Text field, no char limit		N	Skip Logic	OPS Why Not Complete today
CAS0047732		So far, how long have you worked on this online application?	Up to 30 minutes		Radio button select one		Y		Time Spent
			More than 30 minutes up to 1 hour
			More than 1 up to 2 hours
			More than 2 up to 3 hours
			More than 3 up to 4 hours
			More than 4 hours
CAS0047733		How many times did you work on this online application?	One Time		Radio button select one		Y		Number of times
			Two Times
			Three Times
			Four Times
			Five or More Times
CAS0047734		How easy was it for you to find this online application?	Very easy						Find App
			Somewhat easy
			Somewhat hard	A
			Very hard	A
CAS0047735	A	Please tell us why it was hard to find the online application. (Select all that apply.)	Could not find where to start a new online application		check box one up vertical	Multi	Y	Skip Logic	Why hard to find
			Not clear where to go to return to a previously saved application
			It was not clear to me where the links would lead
			Difficulty using a link on the Social Security website
			The information did not seem to be organized in a logical manner
			I used the search feature but the results didn’t seem to apply.
			I tried to use the FAQ's, but couldn't find the online application
			Other reason (please describe)	AA
CAS0047736	AA	Please explain the reason why it was hard for you to find the online application.			N		N	Skip Logic	OPS Hard to Find
CAS0047709		How did you arrive at this online application today?	Used the Online Services link on the Social Security homepage		Radio Button	Single	Y	Skip Logic	Arrive at App
			Followed a link from somewhere else on the Social Security website
			Used the search feature on the Social Security website
			Used an outside search engine (i.e. Google, Bing, yahoo etc.)
			Followed a link from medicare.gov
			Followed a link from another website
			Site was bookmarked
			Other, please specify	A
CAS0047686	A	Please describe how you arrived at this online application today			Text field, no char limit		N		OPS Arrive at app
CAS0045279		Why did you choose to apply online? (Select all that apply.)	I did not want to go to a local Social Security office		check box one up vertical	Multi	Y	Skip Logic	Why Online
			I did not want to apply over the phone
			I prefer to use online services as much as possible
			I learned about applying online while visiting Social Security's website
			A Social Security employee recommended that I apply online
			A friend or relative recommended that I apply online
			I knew that if I had a question or problem applying online, I could still get help from Social Security
			I am filing on behalf of another person
			Other, please specify	A
CAS0045253	A	Please specify why you choose to apply online			Text field, no char limit		N		OPS Why Online
		Would you describe yourself as a Wounded Warrior or a Veteran of the United States military?	Yes		Radio button, one-up vertical	Single	N		Wounded Warrior - Veteran Status
			No
CAS0045254		What is your current marital status?	Married		Radio button, one-up vertical	Single	N	OPS Group	Marital Status
			Separated
			Divorced
			Widowed
			Never married
			Prefer not to answer
			Other, please specify	A
CAS0045255	A	Other marital status			Text field, <100 char		N	OPS Group	OPS Marital Status
STE0059663		Do you presently have an active my Social Security account established?	Yes		Radio button, one-up vertical	Single	Y		Have mySSA Account
			No
CAS0047685		Do you have any suggestions for improving Social Security's online application?			Text Area – no character limit		N		OE_Improvement

---

Sheet 6: Custom Qsts v2 (6-12-14)

Model Instance Name:			red & strike-through: DELETE
SSADisability v2			underlined & italicized: RE-ORDER
MID:	451pZNUxEwhdwdY1JBg4EA4C		pink: ADDITION
Date:	11/1/2010		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
SSADisability v2 CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip To	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Labels
CAS0047707		What type of benefits were you applying for?	Retirement		Dropdown (Select-one)	Single	Y	Skip Logic Group	Type of Benefits
			Medicare only
			Disability
			Both Retirement and Disability
			Spouse's
			Other
CAS0045268		Are you applying online for yourself or are you helping someone else?	Myself		Drop down select one	Single	Y		Applying for
			Helping a Spouse/Relative/Friend
			Professional Helping a Client
			Other
CAS0045269		How did you learn about this online application? (Select all that apply.)	Official Social Security website		Check boc vertical one up	Multi	Y	Skip Logic	Learn about App
			Online search engine or other website
			Social Security employee	A
			Social Security Statement
			Social Security publication
			Relative or friend
			Doctor, social worker, attorney, or other professional
			Traditional media (TV, radio, newspaper, etc.)
			Online social media (Facebook, Twitter, etc.)
			Other, please specify	B
CAS0045270	A	How did you make contact with a Social Security employee?	Visited a local Social Security office		Drop down select one	Single	Y	Skip Logic	How Contact SSA employee
			Called a local Social Security office
			Called the national 800 number
			Other, please specify	AA
CAS0045271	AA	Please describe how you made contact with a Social Security employee.						Skip Logic	OPS how Contact SSA Employee
CAS0045272	B	Please specify how you learned about this online application.			Text box, no char limit		N	Skip Logic	OPS_learned of app
CAS0045273		Did you use any of the following to prepare to apply online? (Select all that apply.)	I used the Disability Benefits Checklist	A	check box one up vertical	Multi	Y	Skip Logic	Prepare for App
			I used the Disability Starter Kit	B
			I watched the instructional video	C
			I used other information on the Social Security website to prepare	D
			I used another resource to prepare to apply online	E
			I did not use any resources to prepare to apply online
CAS0045274	A	How helpful did you find the Disability Benefits Checklist?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Statement
			Somewhat helpful
			Not at all helpful
CAS0045275	B	How helpful did you find the Disability Starter Kit?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate RE Tools
			Somewhat helpful
			Not at all helpful
CAS0045276	C	How helpful did you find the instructional video?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Video
			Somewhat helpful
			Not at all helpful
CAS0045277	D	How helpful did you find the other information on the Social Security website?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Other Info on Website
			Somewhat helpful
			Not at all helpful
CAS0045278	E	Please describe what other resource(s) you used to prepare to apply online?			Text field, no char limit		N	Skip Logic	OPS Prepare for App
CAS0047708		Did you start a new online application today or did you return to a saved application?	Started a new application		Drop down select one	Single	Y		App Status
			Returned to work on a saved application
CAS0047725		Did you complete and submit this online application today?	Yes		Drop down select one	Single	Y	Skip Logic	Complete App
			No, I plan to complete and submit later	A
			No, I do not plan to complete and submit the online application	A
CAS0047730	A	If you did not complete and submit this online application today, please tell us why.	Too many questions		check box one up vertical	Multi	Y	Skip Logic	Not Complete App
			Takes too long to fill out
			Too complicated to use without help
			Didn't have information I needed like names, addresses, or dates
			Didn't understand what questions meant/how to answer
			My disabling condition prevents me from working with a computer for long periods
			I had a limited amount of time/family demands that kept me from working on it for very long
			I had technical problems like an error message or a mistake I couldn't fix
			Other, please specify	AA
CAS0047731	AA	Please tell us why you did not complete and submit this application today.			Text field, no char limit		N	Skip Logic	OPS Why Not Complete today
CAS0047732		So far, how long have you worked on this online application?	Up to 30 minutes		Radio button select one		Y		Time Spent
			More than 30 minutes up to 1 hour
			More than 1 up to 2 hours
			More than 2 up to 3 hours
			More than 3 up to 4 hours
			More than 4 hours
CAS0047733		How many times did you work on this online application?	One Time		Radio button select one		Y		Number of times
			Two Times
			Three Times
			Four Times
			Five or More Times
CAS0047734		How easy was it for you to find this online application?	Very easy						Find App
			Somewhat easy
			Somewhat hard	A
			Very hard	A
CAS0047735	A	Please tell us why it was hard to find the online application. (Select all that apply.)	Could not find where to start a new online application		check box one up vertical	Multi	Y	Skip Logic	Why hard to find
			Not clear where to go to return to a previously saved application
			It was not clear to me where the links would lead
			Difficulty using a link on the Social Security website
			The information did not seem to be organized in a logical manner
			I used the search feature but the results didn’t seem to apply.
			I tried to use the FAQ's, but couldn't find the online application
			Other reason (please describe)	AA
CAS0047736	AA	Please explain the reason why it was hard for you to find the online application.			N		N	Skip Logic	OPS Hard to Find
CAS0047709		How did you arrive at this online application today?	Used the Online Services link on the Social Security homepage		Radio Button	Single	Y	Skip Logic	Arrive at App
			Followed a link from somewhere else on the Social Security website
			Used the search feature on the Social Security website
			Used an outside search engine (i.e. Google, Bing, yahoo etc.)
			Followed a link from medicare.gov
			Followed a link from another website
			Site was bookmarked
			Other, please specify	A
CAS0047686	A	Please describe how you arrived at this online application today			Text field, no char limit		N		OPS Arrive at app
CAS0045279		Why did you choose to apply online? (Select all that apply.)	I did not want to go to a local Social Security office		check box one up vertical	Multi	Y	Skip Logic	Why Online
			I did not want to apply over the phone
			I prefer to use online services as much as possible
			I learned about applying online while visiting Social Security's website
			A Social Security employee recommended that I apply online
			A friend or relative recommended that I apply online
			I knew that if I had a question or problem applying online, I could still get help from Social Security
			I am filing on behalf of another person
			Other, please specify	A
CAS0045253	A	Please specify why you choose to apply online			Text field, no char limit		N		OPS Why Online
CAS0045254		What is your current marital status?	Married		Radio button, one-up vertical	Single	N	OPS Group	Marital Status
			Separated
			Divorced
			Widowed
			Never married
			Prefer not to answer
			Other, please specify	A
CAS0045255	A	Other marital status			Text field, <100 char		N	OPS Group	OPS Marital Status
		Do you presently have an active my Social Security account established?	Yes		Radio button, one-up vertical	Single	Y		Have mySSA Account
			No
CAS0047685		Do you have any suggestions for improving Social Security's online application?			Text Area – no character limit		N		OE_Improvement

---

Sheet 7: Custom Qsts v2 (1-24)

Model Instance Name:			red & strike-through: DELETE
SSADisability v2			underlined & italicized: RE-ORDER
MID:	451pZNUxEwhdwdY1JBg4EA4C		pink: ADDITION
Date:	11/1/2010		blue + -->: REWORDING
			violet (bold): SKIP-LOGIC
SSADisability v2 CUSTOM QUESTION LIST
QID	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip To	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	Labels
		What type of benefits were you applying for?	Retirement		Dropdown (Select-one)	Single	Y	Skip Logic Group	Type of Benefits
			Medicare only
			Disability
			Both Retirement and Disability
			Spouse's
			Other
CAS0045268		Are you applying online for yourself or are you helping someone else?	Myself		Drop down select one	Single	Y		Applying for
			Helping a Spouse/Relative/Friend
			Professional Helping a Client
			Other
CAS0045269		How did you learn about this online application? (Select all that apply.)	Official Social Security website		Check boc vertical one up	Multi	Y	Skip Logic	Learn about App
			Online search engine or other website
			Social Security employee	A
			Social Security Statement
			Social Security publication
			Relative or friend
			Doctor, social worker, attorney, or other professional
			Traditional media (TV, radio, newspaper, etc.)
			Online social media (Facebook, Twitter, etc.)
			Other, please specify	B
CAS0045270	A	How did you make contact with a Social Security employee?	Visited a local Social Security office		Drop down select one	Single	Y	Skip Logic	How Contact SSA employee
			Called a local Social Security office
			Called the national 800 number
			Other, please specify	AA
CAS0045271	AA	Please describe how you made contact with a Social Security employee.						Skip Logic	OPS how Contact SSA Employee
CAS0045272	B	Please specify how you learned about this online application.			Text box, no char limit		N	Skip Logic	OPS_learned of app
CAS0045273		Did you use any of the following to prepare to apply online? (Select all that apply.)	I used the Disability Benefits Checklist	A	check box one up vertical	Multi	Y	Skip Logic	Prepare for App
			I used the Disability Starter Kit	B
			I watched the instructional video	C
			I used other information on the Social Security website to prepare	D
			I used another resource to prepare to apply online	E
			I did not use any resources to prepare to apply online
CAS0045274	A	How helpful did you find the Disability Benefits Checklist?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Statement
			Somewhat helpful
			Not at all helpful
CAS0045275	B	How helpful did you find the Disability Starter Kit?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate RE Tools
			Somewhat helpful
			Not at all helpful
CAS0045276	C	How helpful did you find the instructional video?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Video
			Somewhat helpful
			Not at all helpful
CAS0045277	D	How helpful did you find the other information on the Social Security website?	Very helpful		Drop down select one	Single	Y	Skip Logic	Rate Other Info on Website
			Somewhat helpful
			Not at all helpful
CAS0045278	E	Please describe what other resource(s) you used to prepare to apply online?			Text field, no char limit		N	Skip Logic	OPS Prepare for App
		Did you start a new online application today or did you return to a saved application?	Started a new application		Drop down select one	Single	Y		App Status
			Returned to work on a saved application
		Did you complete and submit this online application today?	Yes		Drop down select one	Single	Y	Skip Logic	Complete App
			No, I plan to complete and submit later	A
			No, I do not plan to complete and submit the online application	A
	A	If you did not complete and submit this online application today, please tell us why.	Too many questions		check box one up vertical	Multi	Y	Skip Logic	Not Complete App
			Takes too long to fill out
			Too complicated to use without help
			Didn't have information I needed like names, addresses, or dates
			Didn't understand what questions meant/how to answer
			My disabling condition prevents me from working with a computer for long periods
			I had a limited amount of time/family demands that kept me from working on it for very long
			I had technical problems like an error message or a mistake I couldn't fix
			Other, please specify	AA
	AA	Please tell us why you did not complete and submit this application today.			Text field, no char limit		N	Skip Logic	OPS Why Not Complete today
		So far, how long have you worked on this online application?	Up to 30 minutes		Radio button select one		Y		Time Spent
			More than 30 minutes up to 1 hour
			More than 1 up to 2 hours
			More than 2 up to 3 hours
			More than 3 up to 4 hours
			More than 4 hours
		How many times did you work on this online application?	One Time		Radio button select one		Y		Number of times
			Two Times
			Three Times
			Four Times
			Five or More Times
		How easy was it for you to find this online application?	Very easy						Find App
			Somewhat easy
			Somewhat hard	A
			Very hard	A
	A	Please tell us why it was hard to find the online application. (Select all that apply.)	Could not find where to start a new online application		check box one up vertical	Multi	Y	Skip Logic	Why hard to find
			Not clear where to go to return to a previously saved application
			It was not clear to me where the links would lead
			Difficulty using a link on the Social Security website
			The information did not seem to be organized in a logical manner
			I used the search feature but the results didn’t seem to apply.
			I tried to use the FAQ's, but couldn't find the online application
			Other reason (please describe)	AA
	AA	Please explain the reason why it was hard for you to find the online application.			N		N	Skip Logic	OPS Hard to Find
		How did you arrive at this online application today?	Used the Online Services link on the Social Security homepage		Radio Button	Single	Y	Skip Logic	Arrive at App
			Followed a link from somewhere else on the Social Security website
			Used the search feature on the Social Security website
			Used an outside search engine (i.e. Google, Bing, yahoo etc.)
			Followed a link from medicare.gov
			Followed a link from another website
			Site was bookmarked
			Other, please specify	A
	A	Please describe how you arrived at this online application today			Text field, no char limit		N		OPS Arrive at app
LNH5329		Did you finish your Disability Report today?	Yes, I started and finished the report today.	D	Radio Button One Up Vertical	Single	Y	Skip Logic Group	Complete Report
			Yes, I finished the report I started before today.	F
			No, I did not finish the report but I plan to finish it later.	G
			No, I do not plan to come back to finish the report.	A, C
LNH5330	A	Please tell us why you decided not to finish your Disability Report.	Too many questions		Checkbox One Up Vertical	Multi	Y	Skip Logic Group	Why didn't Complete
			Takes too long to fill out
			Too complicated to use without help
			My claim was denied less than 60 days ago
			I only had a limited amount of time to spend on it
			I was interrupted, for example by family demands
			I had problems entering dates or other information
			Did not understand what questions meant/how to answer
			I made a mistake on one of the screens, but couldn't correct it
			Received an error message or was "kicked out" of the application
			Didn’t have information like addresses, dates or doctors’ names readily available
			My disabling condition prevents me from working with a computer for long periods
			Other, please specify:	B
LNH5331	B	Please tell us why you have stopped working on your Disability Report.			Text Area – no character limit			Skip Logic Group	OE_Reason for stopping
LNH5332	C	How much time did you spend working on your Disability Report before you decided to stop?	Under 1 hour		Radio Button One Up Vertical	Single	Y	Skip Logic Group	Didn't Complete
			Between 1 and 2 hours
			Between 2 and 3 hours
			Between 3 and 4 hours
			Between 4 and 5 hours
			More than 5 hours
LNH5333	D	How much time did you spend working on your Disability Report today?	Under 1 hour		Radio Button One Up Vertical	Single	Y	Skip Logic Group	Time to Complete
			Between 1 and 2 hours
			Between 2 and 3 hours
			Between 3 and 4 hours
			Between 4 and 5 hours
			More than 5 hours
LNH5334	F	How much time did you spend all together working on your Disability Report?	Under 1 hour		Radio Button One Up Vertical	Single	Y	Skip Logic Group	Time Spent
			Between 1 and 2 hours
			Between 2 and 3 hours
			Between 3 and 4 hours
			Between 4 and 5 hours
			More than 5 hours
LNH5335	G	If you chose not to finish your Disability Report in one sitting, please tell us why.	Too many questions		Checkbox One Up Vertical	Multi	Y	Skip Logic Group	OE_Did not finish in one sitting
			Takes too long to fill out
			Too complicated to use without help
			My claim was denied less than 60 days ago
			I only had a limited amount of time to spend on it
			I was interrupted, for example by family demands
			I had problems entering dates or other information
			Did not understand what questions meant/how to answer
			I made a mistake on one of the screens, but couldn't correct it
			Received an error message or was "kicked out" of the application
			Didn’t have information like addresses, dates or doctors’ names readily available
			My disabling condition prevents me from working with a computer for long periods
			Other, please specify:	H
LNH5336	H	Please specify why you chose not to finish your Disability Report.			Text Area – no character limit		N	Skip Logic Group	OE_Did not finish Report
CAS0045279		Why did you choose to apply online? (Select all that apply.)	I did not want to go to a local Social Security office		check box one up vertical	Multi	Y	Skip Logic	Why Online
			I did not want to apply over the phone
			I prefer to use online services as much as possible
			I learned about applying online while visiting Social Security's website
			A Social Security employee recommended that I apply online
			A friend or relative recommended that I apply online
			I knew that if I had a question or problem applying online, I could still get help from Social Security
			I am filing on behalf of another person
			Other, please specify	A
CAS0045253	A	Please specify why you choose to apply online			Text field, no char limit		N		OPS Why Online
LNH5337		What is the highest level of education you have completed?	Did not graduate from high school		Dropdown (Select-one)	Single	N		Education
			Completed high school or GED
			Some college or university courses, but no degree
			Bachelor’s degree
			Some post-graduate courses
			Master’s degree
			Doctorate
			Prefer not to answer
LNH5338		What is your household income level?	Under $25,000 per year		Dropdown (Select-one)	Single	N		Household Income
			$25,000 to $50,000
			$50,001 to $75,000
			$75,001 to $100,000
			$100,001 to $150,000
			$150,001 to $200,000
			More than $200,000
			Prefer not to answer
CAS0045254		What is your current marital status?	Married		Radio button, one-up vertical	Single	N	OPS Group	Marital Status
			Separated
			Divorced
			Widowed
			Never married
			Prefer not to answer
			Other, please specify	A
CAS0045255	A	Other marital status			Text field, <100 char		N	OPS Group	OPS Marital Status
LNH5339		In addition to completing this Disability Report, did you also fill out Social Security’s Disability Benefit Application online?	Yes		Radio Button One Up Vertical	Single	Y	Skip Logic Group	Disability Application
			No
			Don't know (please explain)	A
LNH5340	A	Please explain:			Text Area – no character limit		N	Skip Logic Group	OE_Disability Application
		Do you have any suggestions for improving Social Security's online application?			Text Area – no character limit		N		OE_Improvement
LNH5341		Please provide any additional comments about your experience with the Internet Disability Report.			Text Area – no character limit		N		OE_Additional Comments

---

Sheet 8: Custom Qsts v2 (12-10)

Model Instance Name:

red & strike-through: DELETE

SSADisability v2

underlined & italicized: RE-ORDER

MID:

451pZNUxEwhdwdY1JBg4EA4C

pink: ADDITION

Date:

11/1/2010

blue + -->: REWORDING

violet (bold): SKIP-LOGIC

SSADisability v2 CUSTOM QUESTION LIST

QID

Skip Logic Label

Question Text

Answer Choices (limited to 50 characters)

Skip To

Type (select from list)

Single or Multi

Required Y/N

Special Instructions

Labels

Are you applying online for yourself or are you helping someone else?

Myself

Drop down select one

Single

Y

Applying for

Helping a Spouse/Relative/Friend

Professional Helping a Client

Other

How did you learn about this online application? (Select all that apply.)

Official Social Security website

Check boc vertical one up

Multi

Y

Skip Logic

Learn about App

Online search engine or other website

Social Security employee

A

Social Security Statement

Social Security publication

Relative or friend

Doctor, social worker, attorney, or other professional

Traditional media (TV, radio, newspaper, etc.)

Online social media (Facebook, Twitter, etc.)

Other, please specify

B

A

How did you make contact with a Social Security employee?

Visited a local Social Security office

Drop down select one

Single

Y

Skip Logic

How Contact SSA employee

Called a local Social Security office

Called the national 800 number

Other, please specify

AA

AA

Please describe how you made contact with a Social Security employee.

Skip Logic

OPS how Contact SSA Employee

B

Please specify how you learned about this online application.

Text box, no char limit

N

Skip Logic

Did you use any of the following to prepare to apply online? (Select all that apply.)

I used the Disability Benefits Checklist

A

check box one up vertical

Multi

Y

Skip Logic

Prepare for App

I used the Disability Starter Kit

B

I watched the instructional video

C

I used other information on the Social Security website to prepare

D

I used another resource to prepare to apply online

E

I did not use any resources to prepare to apply online

A

How helpful did you find the Disability Benefits Checklist?

Very helpful

Drop down select one

Single

Y

Skip Logic

Rate Statement

Somewhat helpful

Not at all helpful

B

How helpful did you find the Disability Starter Kit?

Very helpful

Drop down select one

Single

Y

Skip Logic

Rate RE Tools

Somewhat helpful

Not at all helpful

C

How helpful did you find the instructional video?

Very helpful

Drop down select one

Single

Y

Skip Logic

Rate Video

Somewhat helpful

Not at all helpful

D

How helpful did you find the other information on the Social Security website?

Very helpful

Drop down select one

Single

Y

Skip Logic

Rate Other Info on Website

Somewhat helpful

Not at all helpful

E

Please describe what other resource(s) you used to prepare to apply online?

Text field, no char limit

N

Skip Logic

OPS Prepare for App

LNH5318

How did you hear about the Internet Disability Report?

A Social Security Representative told me about it

A

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Source

Types

From Social Security's website, socialsecurity.gov

Open-ended

Read about it in a Social Security publication

Text Field – limited to 100 characters

Saw it in a newspaper, magazine, television, or other media source

Text Area – no character limit

Got it from an Internet Search Engine or linked from another website

Dropdown (Select-one)

From a social worker, attorney, or other professional

Radio Button One Up Vertical

Word-of-mouth

Radio Button Two Up Vertical

Other, please specify:

B

Radio Button Three Up Vertical

LNH5319

B

Please specify how you heard about the Internet Disability Report

Text Field – limited to 100 characters

N

Skip Logic Group

OE_How hear about

LNH5320

A

When the representative told you about the Internet Disability Report, did he or she tell you about the Disability Starter Kit?

Yes, the representative gave me a paper Disability Starter Kit.

C

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Rep_Disability Starter Kit

Yes, the representative mailed me a Disability Starter Kit.

C

Yes, the representative told me how to go online and get the Disability Starter Kit.

C

No

Don't know

LNH5321

C

Did the Disability Starter Kit help you complete the online Disability Report?

Yes

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Disability Starter Kit_Help Complete

No

LNH5322

I started filling out the Disability Report because…(Select one)

I am applying for disability benefits for myself

Radio Button One Up Vertical

Single

Y

Skip Logice Group

Fill out Report

Radio Button Scale No Don’t Know

I am helping my husband or wife

Checkbox One Up Vertical

I am helping another relative

Select-multiple Show Two

I am helping a client in my professional capacity

B

I am helping a friend

Select-multiple Show Three

Other, please specify:

A

Select-multiple Show Four

LNH5323

A

Please specify your role in filling out the Disability Report.

Text Field – limited to 100 characters

N

Skip Logice Group

OE_Reason for filling

LNH5324

B

If you are helping a client, what is your role? (Select one)

I am an attorney

Radio Button One Up Vertical

Single

Y

Skip Logice Group

Role in Helping Client

I am a non-attorney representative

I work for an insurance company

I work for a government agency

I work for a not-for-profit organization

I work for a for-profit organization

I work for a hospital, nursing care facility, or health services agency

Other, please specify:

C

LNH5325

C

Please specify your role.

Text Field – limited to 100 characters

N

Skip Logice Group

Role

LNH5326

Did you download, print, or view the Social Security “Disability Benefits Checklist” before starting your Disability Report?

Yes

A

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Disability Starter Kit

No

Don't know what that is

LNH5327

A

Did you find the checklist helpful while completing your application?

Yes

B

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Helpfulness of Checklist

No

Don't know

LNH5328

B

Please rate how helpful the Disability Benefits Checklist was for you.

Extremely helpful

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Rate Helpfulness of Checklist

Very helpful

Moderately helpful

Slightly helpful

Helpful, but barely

Not helpful

LNH5329

Did you finish your Disability Report today?

Yes, I started and finished the report today.

D

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Complete Report

Yes, I finished the report I started before today.

F

No, I did not finish the report but I plan to finish it later.

G

No, I do not plan to come back to finish the report.

A, C

LNH5330

A

Please tell us why you decided not to finish your Disability Report.

Too many questions

Checkbox One Up Vertical

Multi

Y

Skip Logic Group

Why didn't Complete

Takes too long to fill out

Too complicated to use without help

My claim was denied less than 60 days ago

I only had a limited amount of time to spend on it

I was interrupted, for example by family demands

I had problems entering dates or other information

Did not understand what questions meant/how to answer

I made a mistake on one of the screens, but couldn't correct it

Received an error message or was "kicked out" of the application

Didn’t have information like addresses, dates or doctors’ names readily available

My disabling condition prevents me from working with a computer for long periods

Other, please specify:

B

LNH5331

B

Please tell us why you have stopped working on your Disability Report.

Text Area – no character limit

Skip Logic Group

OE_Reason for stopping

LNH5332

C

How much time did you spend working on your Disability Report before you decided to stop?

Under 1 hour

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Didn't Complete

Between 1 and 2 hours

Between 2 and 3 hours

Between 3 and 4 hours

Between 4 and 5 hours

More than 5 hours

LNH5333

D

How much time did you spend working on your Disability Report today?

Under 1 hour

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Time to Complete

Between 1 and 2 hours

Between 2 and 3 hours

Between 3 and 4 hours

Between 4 and 5 hours

More than 5 hours

LNH5334

F

How much time did you spend all together working on your Disability Report?

Under 1 hour

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Time Spent

Between 1 and 2 hours

Between 2 and 3 hours

Between 3 and 4 hours

Between 4 and 5 hours

More than 5 hours

LNH5335

G

If you chose not to finish your Disability Report in one sitting, please tell us why.

Too many questions

Checkbox One Up Vertical

Multi

Y

Skip Logic Group

OE_Did not finish in one sitting

Takes too long to fill out

Too complicated to use without help

My claim was denied less than 60 days ago

I only had a limited amount of time to spend on it

I was interrupted, for example by family demands

I had problems entering dates or other information

Did not understand what questions meant/how to answer

I made a mistake on one of the screens, but couldn't correct it

Received an error message or was "kicked out" of the application

Didn’t have information like addresses, dates or doctors’ names readily available

My disabling condition prevents me from working with a computer for long periods

Other, please specify:

H

LNH5336

H

Please specify why you chose not to finish your Disability Report.

Text Area – no character limit

N

Skip Logic Group

OE_Did not finish Report

Why did you choose to apply online? (Select all that apply.)

I did not want to go to a local Social Security office

check box one up vertical

Multi

Y

Skip Logic

Why Online

I did not want to apply over the phone

I prefer to use online services as much as possible

I learned about applying online while visiting Social Security's website

A Social Security employee recommended that I apply online

A friend or relative recommended that I apply online

I knew that if I had a question or problem applying online, I could still get help from Social Security

I am filing on behalf of another person

Other, please specify

A

A

Please specify why you choose to apply online

Text field, no char limit

N

OPS Why Online

LNH5337

What is the highest level of education you have completed?

Did not graduate from high school

Dropdown (Select-one)

Single

N

Education

Completed high school or GED

Some college or university courses, but no degree

Bachelor’s degree

Some post-graduate courses

Master’s degree

Doctorate

Prefer not to answer

LNH5338

What is your household income level?

Under $25,000 per year

Dropdown (Select-one)

Single

N

Household Income

$25,000 to $50,000

$50,001 to $75,000

$75,001 to $100,000

$100,001 to $150,000

$150,001 to $200,000

More than $200,000

Prefer not to answer

What is your current marital status?

Married

Radio button, one-up vertical

Single

N

OPS Group

Marital Status

Separated

Divorced

Widowed

Never married

Prefer not to answer

Other, please specify

A

A

Other marital status

Text field, <100 char

N

OPS Group

OPS Marital Status

LNH5339

In addition to completing this Disability Report, did you also fill out Social Security’s Disability Benefit Application online?

Yes

Radio Button One Up Vertical

Single

Y

Skip Logic Group

Disability Application

No

Don't know (please explain)

A

LNH5340

A

Please explain:

Text Area – no character limit

N

Skip Logic Group

OE_Disability Application

LNH5341

Please provide any additional comments about your experience with the Internet Disability Report.

Text Area – no character limit

N

OE_Additional Comments