Category A Sample

OMB Control No. 0960-0526

Expiration Date:

Give Social Security a Report Card…

Help us improve the service you get from Social Security.
Please rate Social Security based on your recent office visit.
E = Excellent VG = Very Good G = Good	F = Fair P = Poor VP = Very Poor
Circle ONE rating for every item.
1. Office location		E	VG	G	F	P	VP
2. Office hours		E	VG	G	F	P	VP
3. Signs/instructions explaining how to check in when you got to the office		E	VG	G	F	P	VP
4. Office comfort (seating, temperature, etc.)		E	VG	G	F	P	VP
5. Office appearance (clean, pleasant, etc.)		E	VG	G	F	P	VP
6. Office privacy		E	VG	G	F	P	VP
7a. Did you have an appointment? Check one:  Yes  (Go to 7b.)  No  (Skip to 8a.)
7b. Convenience of your appointment		E	VG	G	F	P	VP
8a. Waiting time to be helped		E	VG	G	F	P	VP
8b. About how many minutes did you have to wait? Check only ONE:  Less than 10 minutes More than 10 and up to 30 minutes More than 30 and up to 60 minutes More than 60 minutes

Circle ONE rating for every item.
9. Helpfulness of the staff	E	VG	G	F	P	VP
10. Courtesy of the staff	E	VG	G	F	P	VP
11. How well the staff knew their jobs	E	VG	G	F	P	VP
12. How clearly the staff explained things	E	VG	G	F	P	VP
13. Was Social Security able to take care of your business completely that day? Check one:  Yes  No
14. Overall, how would you rate Social Security’s service for your recent office visit?	E	VG	G	F	P	VP
15. If you contact Social Security again, what are you most likely to do? Will you: Check only ONE:  Call Social Security’s 800 number  Call the local Social Security office  Visit the local office  Use the Internet or email  Other Explain:__________________________________________
Social Security has its own Internet site, www.socialsecurity.gov, that provides Social Security information and services online. We’d like to ask you a few questions about doing business on the Internet. 16. First, do you currently use the Internet? Check one:  Yes  No  (Skip to 19.)
17. Have you ever visited Social Security’s Internet site? Check one:  Yes  No
18. If you could have taken care of your recent business by using the Internet instead of visiting Social Security, how likely would you have been to do that? Would you have been: Check only ONE:  Very likely  Somewhat likely Not very likely, or Not at all likely to use the Internet instead of visiting
19. Please use this space to explain why you rated any item “F” (fair), “P” (poor), or “VP” (very poor) or to explain any of your other answers. ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

Thank you for taking the time to rate Social Security! Please send us your “Report Card” in the enclosed postage-paid envelope as soon as possible.

PRIVACY ACT STATEMENT

 

The Social Security Administration is authorized to collect the information for this survey under Executive Order 12862, “Setting Customer Service Standards.” Your response to these questions is strictly voluntary. The information you provide will be used to help us improve the service that we give you. Your response will not be disclosed to any other government or private agency.

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 read the instructions, gather the facts, and answer the questions. You may send comments on our time estimate above to: Social Security Administration, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this address, not the completed form.

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