Form FEMA Form 419-0-47 FEMA Form 419-0-47 Transitional Shelter Assistance Survey- Electronic

T RANSITIONAL SHELTERING ASSISTANCE (TSA) Survey- Electronic

OMB Control Number 1660-NW103

Expiration XXX

PAPERWORK BURDEN DISCLOSURE NOTICE

FEMA Form 519-0-47 (Transitional Sheltering Assistance Electronic Survey)

Public reporting burden for this data collection is estimated to average 10 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. This collection of information is voluntary. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street, SW., Washington, DC 20472-3100, Paperwork Reduction Project (PROGNEW) NOTE: Do not send your completed form to this address.

PRIVACY ACT STATEMENT

AUTHORITY: Government Performance and Results Act of 1993 (Pub. L. 103-62), as amended, and the GPRA Modernization Act of 2010 (Pub. L. 111-352); Executive Order (EO) 12862, “Setting Customer Service Standards”; and its March 23, 1995 Memorandum addendum, “Improving Customer Service”; Executive Order 13411 “Improving Assistance for Disaster Victims”; Executive Order 13571 “Streamlining Service Delivery and Improving Customer Service”; and the related June 13, 2011 Memorandum “Implementing Executive Order 13571 on Streamlining Service Delivery and Improving Customer Service.”

PRINCIPAL PURPOSE(S): DHS/FEMA collects this information to measure Individual Assistance applicants’ customer satisfaction with FEMA services.

ROUTINE USE(S): This information is used for the principal purpose noted above and will not be shared outside of DHS/FEMA, except as allowed under the routine uses published in System of Records Notice DHS/FEMA-008 - Disaster Recovery Assistance Files, 78 FR 25282 (April 30, 2013), or as required by law. The Department's system of records notices can be found on the Department's website at http://www.dhs.gov/system-records-notices-sorns.

DISCLOSURE: The disclosure of information on this form is strictly voluntary and will assist FEMA is making improvements to its Individual Assistance program; failure to provide the information requested will not impact an individual’s ability to qualify for or receive FEMA Individual Assistance.

Introduction – Electronic (Applicable for sample records where the applicant requested electronic correspondence from FEMA)

FEMA is looking for ways to improve the quality of our services and your opinion is very important. This questionnaire should be completed by the person in the household most familiar with the FEMA application. The survey will take 8-10 minutes to complete.

These questions comply with the Privacy Act of 1974 and have been approved by the Office of Management and Budget under number (New OMB Number). Your answers will not affect the outcome of your application for FEMA assistance.

Please click Next to begin the survey:

INFORMATION

FEMA’s Transitional Sheltering Assistance provided you with sheltering accommodations at a participating hotel or motel. The first set of questions are about information provided by FEMA prior to, during and after your stay. Using a scale of 1 to 5, with 1 being Poor and 5 being Excellent, please rate the information on:

	1 Poor	2	3	4	5 Excellent	No Information received
1. Being easy to understand
2. Answering your questions
3. Being helpful
4. Explaining what happens next
5. Overall satisfaction with information

FEMA may have provided Transitional Sheltering information to you through a variety of methods. Please provide your opinion about each method using a rating scale of 1 to 5, with 1 being Not at all Effective and 5 being Very Effective, or saying Not applicable if you did not receive information using that method. How would you rate information provided by:

	1 Not at Effective	2	3	4	5 Very Effective	Not Applicable
6. E-mail
7. Text message
8. Phone call or message received from FEMA
9. Phone call you made to FEMA’s helpline
10. DisasterAssistance.gov website
11 FEMA Evacuee Hotel List website

CUSTOMER SERVICE

The next set of questions are about the level of customer service provided by FEMA staff. Using a scale of 1 to 5, with 1 being Poor and 5 being Excellent, please rate FEMA Representatives on:

	1 Poor	2	3	4	5 Excellent	Did not talk to FEMA Representative
12. Courtesy
13. Showing interest in helping
14. Overall customer service

ACCOMMODATIONS

Using a scale of 1 to 5, with 1 being Not at all Satisfied and 5 being Very Satisfied, how would you rate the Transitional Sheltering provided by FEMA on the following:

	1 Not at all Satisfied	2	3	4	5 Very Satisfied	Not Applicable
15. Ease in finding a TSA participating hotel/motel with room availability
16. Accessibility for household members with disabilities and/or access functional needs
17. Conveniently located
18. Access to public transportation
19. Access to food services
20. Clean and well-maintained
21. Accepting household pets
22. Overall satisfaction with the accommodations

OVERALL EXPERIENCE

Thinking back on your overall Transitional Sheltering Hotel/Motel experience, using a rating scale of 1 to 5, with 1 being Poor and 5 being Excellent, how would you rate FEMA on:

	1 Poor	2	3	4	5 Excellent
23. Making it easy to know your eligibility status
24. Timeliness of extension eligibility or ineligibility notifications
25. Helping to meet sheltering needs caused by the disaster

26. What suggestions do you have for improving FEMA’s Transitional Sheltering Assistance? (500 Character Maximum)

Demographics

27. We’re almost done. Would you volunteer to answer a few demographic questions for statistical purposes?

• Yes

• No

(Programmer Note: If Q27 response = Yes go to 28 else go to Q34)

28. Is your gender…

• Female

• Male

• Prefer not to answer

29. Is your age range..

• Under 25

• 25 to 34

• 35 to 44

• 45 to 54

• 55 to 64

• 65 to 74

• 75 or older

• Prefer not to answer

30. Is your marital status…

• Single

• Married

• Separated

• Widowed

• Divorced

• Prefer not to answer

31. Is your current employment status…

• Employed for wages

• Self-employed

• Unemployed

• Homemaker

• Student

• Retired

• Prefer not to answer

32. Which of the following best describes your highest level of formal education:

• Did not complete high school

• High school graduate / GED

• Some college

• Associate degree

• Bachelor’s degree

• Master’s degree

• Doctoral degree

• Prefer not to answer

33. Which of the following is your race or ethnic group? You may select all that apply.

• American Indian or Alaska Native

• Asian

• Black or African American

• Hispanic or Latino

• Native Hawaiian or Other Pacific Islander

• White

• Prefer not to answer

34. Your opinion is very valuable to us, may we contact you at a later date to ask some additional questions?

• Yes

• No

CLOSING ELECTRONIC SURVEY

Press any key or click on the X button to submit your survey. Thank you for your time. Have a good day/evening.