Survey 1 Competency Screening

ATTACHMENT A9. SURVEY 1 SCREENER AND CALLBACK SCRIPT
Survey 1 –Screener
S1.

Hello, may I speak with [BENEFICIARY]? [IF NEEDED: I am trying to reach the person who
recently received a letter from the SSA about a research study]
[IF ASKED, “WHO’S CALLING?”]:
My name is (DATA COLLECTOR) and I am calling from Westat about a Social Security
Administration research study.
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YES/SPEAKING  (GO TO INTRO1)
ANSWERING MACHINE  (GO TO ANSWERING MACHINE MESSAGE)
ENTER NEW PHONE NUMBER  (GO TO RECORD NEW NUMBER)
CLICK FREDK TAB, CODE RESULT CODE  (GO TO START SCREENER)

ANSWERING MACHINE MESSAGE
(DISPLAY ANSWERING MACHINE MESSAGE ONLY IF ONE HAS NOT BEEN LEFT PREVIOUSLY)
Hello, I’m calling from Westat about a Social Security Administration research study. The study is
voluntary. If you complete the survey, you will receive a Visa pre-paid debit card in the amount of $50.
We will call back within the next few days, or you can call our toll-free number: [INSERT TOLL-FREE
NUMBER]. Thank you.
RECORD A NEW PHONE NUMBER:
(e.g., 301-444-4444)
TELEPHONE NUMBER:
[INTRO1]
Hello, this is (INTERVIEWER) and I’m calling from Westat about a Social Security Administration (SSA)
research study. The Social Security Administration is conducting this study and Westat is supporting
them. We recently sent you a letter about the study. I am calling now to invite you to participate in the
study.

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ATTACHMENT A9. SURVEY 1 SCREENER AND CALLBACK SCRIPT

S2.

First, are you age 18 or older?
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YES  (GO TO INTO2)
NO  (GO TO THANK1)
REFUSE  (GO TO THANK1)
DON’T KNOW  (GO TO THANK1)

[INTRO2]
Now, I am going to explain to you what you will do in the study. Please listen carefully as I will ask you a
question at the end to be sure that you understand what you will do.
We need you to complete 2 surveys. These surveys will ask you questions about your functioning. You
will need to answer the questions that you are comfortable answering. You can complete Survey 1
during this call or at later time more convenient to you. You can decide to do Survey 1 with an
interviewer over the telephone, or you can do it on your own over the internet. After you complete
Survey 1, you will receive a Visa pre-paid debit card in the amount of $50. Approximately 6 months after
you complete Survey 1 we will call again to invite you to complete Survey 2, which will ask you more
questions about your functioning. You will need to answer those questions too. You may also decide to
do Survey 2 with an interviewer over the telephone, or you can do it on your own over the internet.
After you complete Survey 2, you will receive another debit card for your time, this time in the amount
of $75.
Now, I need to ask you…

S3.

Please name 1 thing you will do in this study?

[NOTE TO INTERVIEWER: RESPONDENT MUST BE ABLE TO PROVIDE 1 OF THE POSSIBLE RESPONSES
BELOW.]
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I WILL DO A SURVEY
I WILL DO 2 SURVEYS / I WILL ANSWER QUESTIONS 2 TIMES (CONTACT FREQUENCY)
I WILL ANSWER QUESTIONS THAT I AM COMFORTABLE ANSWERING
I WILL TAKE ONE SURVEY NOW (CONTACT FREQUENCY)
I WILL TAKE THE NEXT SURVEY 6 MONTHS AFTER I COMPLETE THE FIRST SURVEY (CONTACT
FREQUENCY)
I WILL ANSWER QUESTIONS ABOUT MY FUNCTIONING/HOW I DO THINGS/MY ACTIVITIES
(SURVEY CONTENT).
I WILL TAKE THE SURVEY/ANSWER QUESTIONS OVER THE INTERNET/ON-LINE BY MYSELF
(ADMINISTRATION MODE).

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ATTACHMENT A9. SURVEY 1 SCREENER AND CALLBACK SCRIPT
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I WILL TAKE THE SURVEY/ANSWER QUESTIONS WITH INTERVIEWER OVER THE TELEPHONE
DURING THIS CALL OR AT A LATER TIME (ADMINISTRATION MODE).
I WILL RECEIVE A DEBIT CARD FOR TAKING A SURVEY/ASNWERING QUESTIONS
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S4.

ACCURATE ANSWER
INACCURATE ANSWER (GO TO THANK1) [CLICK FREDK TAB, CODE “IN”]
REFUSE (GO TO THANK1) [CLICK FREDK TAB, CODE “2”]
DON’T KNOW (GO TO THANK1) [CLICK FREDK TAB, CODE “IN”]

BENEFICIARY CONSENT: Let me review the consent form that we sent to you in the mail:
Please remember that it is your choice whether to participate in this study. This study is not
related to the benefits you receive and whether or not you participate will not affect your
current or any future benefits. If you do participate, please realize that you do not give up any of
your legal rights. If you withdraw from the study at any time it will not affect you in any
way. Nothing in the study will directly benefit you. Hopefully, it will benefit future SSA or SSDI
beneficiaries.
Survey 1 takes about 50 minutes and Survey 2 will take about 75 minutes. You may obtain
further information about your rights as a research participant by calling the Office of the
Institutional Review Board or the Project Director at Westat. Their contact information is on the
copy of the consent form we mailed to you.
Do you wish to participate in the study?
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S5.

YES
NO  (GO TO THANK1)

PRIVACY ACT STATEMENT: We look forward to your participation in the study. Before we begin,
let me review the Privacy Act Statement that is included on the back of the letter you received in
the mail:
Section 1110(a) of the Social Security Act allows us to collect the information you provide, which
we will use for research purposes. Providing this information is voluntary. However, failing to
provide all or part of the information may only affect your eligibility to receive the study
participation reimbursement amount. We may disclose your information as law permits,
including to contractors under contract for the performance of research and statistical activities,
and others listed in routine uses in System of Records Notice 60-0199; available at
www.ssa.gov/privacy. Your information may also be used in computer matching programs to
establish or verify eligibility for Federal benefit programs and debts under these programs.
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S6.

CONTINUE SCREENER (GO TO S6)

First, do you have a cell phone that we can text reminder messages about the study?

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ATTACHMENT A9. SURVEY 1 SCREENER AND CALLBACK SCRIPT
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S7.

YES
NO  (GO TO S8)

What is your cell phone number starting with the area code?
CELL PHONE NUMBER: __ __ __-__ __ __-__ __ __ __

S8.

After you have completed Survey 1, we will mail you a Visa pre-paid debit card in the amount of
$50. I would like to confirm that the mailing address we have for you is correct. [INTERVIEWER:
CHECK BENEFICIARY’S ADDRESS LISTED AT THE TOP OF THE SCREEN].
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S9.

S10.

S11.

Would you like to give us your current mailing address so that we can send you a Visa pre-paid
debit card in the amount of $50 when you are done with Survey 1 or would you prefer to
complete the survey and not receive a debit card?
 I WILL GIVE MY ADDRESS  (GO TO S10)
 I WILL NOT GIVE ADDRESS BUT WILL DO SURVEY  (GO TO S11)
 REFUSE BOTH ADDRESS AND SURVEY  (GO TO THANK1)
 DON’T KNOW  (GO TO THANK1)
What is your correct mailing address?
STREET 1:___________________________
STREET 2:______________________________
CITY:_____________________________ STATE:_______________ZIPCODE:_____________
You have the option of doing the survey over the phone now with me or I can schedule the
interview for a different time. You can also go on the Internet to complete the survey on your
own. Which would you prefer?
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S12.

CORRECT ADDRESS  (GO TO S11)
INCORRECT ADDRESS  (GO TO S9)
REFUSE  (GO TO S9)
DON’T KNOW/DON’T REMEMBER  (GO TO S9)

INTERNET  (GO TO S12)
TELEPHONE NOW  (GO TO S13)
TELEPHONE LATER  (GO TO THANK2)

We will send you an email with an access code and instructions for logging on to the web
survey. Please keep in mind that your access code will expire after 7 days. If you try to log into
the survey more than 7 days from now, your access code will not work. May I please have your
email address?
[NOTE TO INTERVIEWER, RESPONDENT CANNOT DO SURVEY ON INTERNET IF THEY DO NOT
HAVE AN EMAIL ADDRESS OR REFUSE TO PROVIDE AN EMAIL ADDRESS FOR US TO SEND THE
SURVEY LINK.]

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ATTACHMENT A9. SURVEY 1 SCREENER AND CALLBACK SCRIPT
E-MAIL ADDRESS ____________________________
CONFIRM E-MAIL ADDRESS ____________________(GO TO THANK3)
S13.

Survey 1 will take about 50 minutes of your time. If you are ready, let’s begin.
• CONTINUE TO SURVEY 1  (GO TO SURVEY 1)

THANK1.

Thank you, but those are all the questions I have for you. Good-bye. (ADD “NEXT CASE”
BUTTON TO TAKE INTERVIEWER TO THE NEXT BENEFICIARY.)

THANK2.

Thank you for taking the time to answer these questions. We look forward to your
participation in our study. (ADD “NEXT CASE” BUTTON TO TAKE INTERVIEWER TO THE
NEXT BENEFICIARY.)

THANK3.

Thank you for taking the time to answer these questions. You should receive an email
with a link for the web survey soon. We look forward to your participation in our study.
(ADD “NEXT CASE” BUTTON TO TAKE INTERVIEWER TO THE NEXT BENEFICIARY.)

INTERVIEWER SCRIPT FOR “TELEPHONE LATER” (S8 ABOVE) BENEFICIARIES:
Hello, may I speak with {SUBJECT NAME}?
This is {DATA COLLECTOR}. I’m calling back from Westat about a Social Security Administration
Study. We spoke earlier regarding this study and are calling back now to complete the interview.
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YES/SPEAKING  (GO TO INTRO3)
ANSWERING MACHINE  GO TO ANSWERING MACHINE MESSAGE)
ENTER NEW PHONE NUMBER  (GO TO RECORD NEW NUMBER)
CLICK FREDK TAB, CODE RESULT CODE  (GO TO START SCREENER)

[INTRO3— “TELEPHONE LATER” BENEFICIARY CONSENT]
The purpose of the study is to see if a newly developed set of questions about functioning can improve
the continuing disability review (CDR) process that SSA uses to determine continued eligibility of
program benefits. SSA is working with the survey research company, Westat, to conduct this study. You
can decide if you want to take part in this study or not. This study is voluntary and will not affect your
current or future benefits in any way. The study takes about 50 minutes. When you have completed all
of the questions, you will receive a Visa pre-paid debit card in the amount of $50.
Do you wish to continue?

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ATTACHMENT A9. SURVEY 1 SCREENER AND CALLBACK SCRIPT
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THANK1.

YES  (GO TO SURVEY 1)
CALLBACK/APPOINTMENT  (GO TO THANK1)
REFUSE  (GO TO THANK1)
DON’T KNOW  (GO TO THANK1)

Thank you, but those are all the questions I have for you. Good-bye.

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ATTACHMENT A9. SURVEY 1 SCREENER AND CALLBACK SCRIPT
Restart Text for Callbacks/Survey Breakoffs
Hello, may I speak with {SUBJECT NAME}?
This is {DATA COLLECTOR}. I’m calling back from Westat about a Social Security Administration
Study. We spoke earlier regarding this study and are calling back now to complete the interview.
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YES/SPEAKING  (GO TO INTRO1)
ANSWERING MACHINE  (GO TO ANSWERING MACHINE MESSAGE)
ENTER NEW PHONE NUMBER  (GO TO RECORD NEW NUMBER)
CLICK FREDK TAB, CODE RESULT CODE  (GO TO START SCREENER)

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