Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

U.S. DEPARTMENT OF STATE
AMERICAN CITIZEN SERVICES APPLICANT
SATISFACTION SURVEY

OMB No: 1405-0193

Expiration Date: 07/31/2017

Estimated Burden: 3 minutes
SV-2015-0005

We ask that you take a brief survey to assess your experience with the United States consular section at the U.S. [Embassy/Consulate General name]. Your responses will be kept private and not associated with you or your case. We are only conducting this survey to improve our service.

1. U.S. Embassy/Consulate General _[Dropdown option choices for electronic survey or write-in option for paper]_
   
   
   

2. Indicate service received:

• U.S. Passport

• Consular Report of Birth Abroad

• Notary Services

• Other ____________________________

If used,
was source helpful?

PREPARING FOR YOUR APPOINTMENT

1. 3. How did you obtain information to prepare for your appointment? Check all that apply.

	Yes	No
Family member or friend
Attorney/Notary
Consultant
U.S. Department of State website (travel.state.gov)
[Embassy/Consulate General name] website in English
[Embassy/Consulate General name] website in [country’s official language]
[Embassy/Consulate General name] phone or email in English
[Embassy/Consulate General name] phone or email in [country’s official language]
[Embassy/Consulate General name] social media (e.g., Facebook, Twitter)
Other ____________________________

4. Did you need help in completing the forms?

• No

• Yes, by a family member or friend

• Yes, by an attorney/notary

• Yes, by contacting the [Embassy/Consulate General name] by phone or email in English

• Yes, by contacting the [Embassy/Consulate General name] by phone or email in [country’s official language]

• Yes, other ____________________________

• No forms were required for the service I received.

4. If you used the [Embassy/Consulate General name] website, were instructions and requirements clear (i.e., documents needed for appointment, items allowed inside the [Embassy/Consulate General])?

• Yes

• No

• I did not use the [Embassy/Consulate General name] website

4. Prior to your appointment, which of the following would you have liked to receive additional information about?

• What to expect at the appointment (i.e., the security process, waiting room experience, parking, appointment time and duration)

• Prohibited items that are not allowed in the [Embassy/Consulate General name]

• Supporting documentation required (e.g., proof of identity, birth certificate)

• Information on how to change appointment time

• Document delivery service

• Other ______________________________________

APPOINTMENT SCHEDULING

4. Was it convenient to make an appointment for the date and time you wanted?

• Yes

• No, I needed an earlier appointment date, and one was not available.

• No, other: _______________________________________________

4. If it was difficult for you to schedule or reschedule your appointment, please indicate why. Check all that apply.

• The scheduling or rescheduling process was confusing.

• I do not have access to or use the internet.

• I had to call the [Embassy/Consulate General].

• Other_________________________________________

DURING THE APPOINTMENT

9. Please rate your visit to [Embassy/Consulate General name].	Excellent	Satisfactory	Needs Improvement
Courtesy of the security guards
Courtesy of the consular staff
Answers to your questions
Explanation regarding your case
Cleanliness and comfort of the waiting area
Duration of wait time

10. Please use the space below for any additional suggestions on what we could improve.

Public reporting burden for this collection of information is estimated to average 3 minutes per response, including time required for searching existing data sources, gathering the necessary documentation, providing the information and/or documents required, and reviewing the final collection. You do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of this burden estimate and/or recommendations for reducing it, please send them to: Department of State, Bureau of Consular Affairs, ATTN: Catherine Barry, 600 19^th Street, N.W., Washington, DC 20036.

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