1210-0161 Gallup Customer Service Survery Instrument with Additional Demographic questions added CLEAN

Outbound
US DOL EBSA CE3 2019 Q2			Export Date: 12/2/19
US Department of Labor
Project #			Translations: YES		Verbatims: YES
Practice: Customer	QBank Id: 14958		Field Date: February, 2019		Quota:
Eldo Project:		Study Code:		Group ID:
DOL EBSA QRT 1 2019
PA:			CS: CAMILLE LLOYD
			CS: DAWN ROYAL
DESIGNER:			PROGRAMMER:

QID:120772 Gallup^®, The Gallup Poll^®, and CE^11® are trademarks of Gallup, Inc. All other trademarks are the property of their respective owners. Copyright © 1994-2000, 2010-2019 Gallup, Inc. All rights reserved.

CASEID

QID:36526 I.D.#

CASEID(1-6)

FVALIFON

QID:1528 **AREA CODE AND TELEPHONE NUMBER:

FVALIFON(1161-1179)

CINTTIME

QID:963 **INTERVIEW TIME:

CINTTIME(1716-1721)

SA

QID:134507 DATE OF INTERVIEW:

SA(1931-1938)

SB

QID:134508 INQUIRY RECORD NUMBER (CONTROL_ID):

(Programmer: Code from fone file)

SB(60-74)

SC

QID:134509 BENEFIT ADVISOR NUMBER/ID (STAFF):

(Programmer: Code from fone file)

SC(195-204)

SD

QID:134510 DATE CLOSED (CLOSING_DATE):

(Programmer: Code from fone file)

SD(245-264)

SE

QID:45204 INQUIRER FIRST NAME (FIRST_NAME):

(Programmer: Code from fone file)

SE(75-109)

SF

QID:3213 INQUIRER LAST NAME (LAST_NAME):

(Programmer: Code from fone file)

SF(110-154)

SK

QID:47255 INQUIRER ZIP CODE (ZIP_CODE):

(Programmer: Code from fone file)

SK(175-184)

SL

QID:134511 CLOSURE ANALYSIS (CLOSURE_ANALYSIS):

(Programmer: Code from fone file)

(Programmer: Allow 5 entries)

01	Benefit Claim – Assistance (BCA)
02	Recovery (BVR)
03	Referral for Enforcement (BVE)
04	Secondary Lead (BVESL)
05	Referral as Abandoned Plan (BVADV)
06	Not Valid (BN)

# of Responses: 5

SL(401-402)

SL_1(516-517)

SL_2(518-519)

SL_3(520-521)

SL_4(522-523)

SL_5(524-525)

SM

QID:134512 SUBJECT ENTRY CODE (SUBJECT):

(Programmer: Code from fone file)

(Programmer: Allow 5 entries)

001	NBI: Not Benefits Issue
002	NCP: Not Covered Pension
003	NCW: Not Covered Welfare
004	NTI: Not Title I Issue
005	PRE: Pre-ERISA
006	UNK: Unknown
007	GER: General EBSA Request
008	RD: Reporting & Disclosure
009	PDD: Disclosure Requirements
010	PDR: Reporting Requirements
011	JSQDRO: Joint & Survivor, QDRO
012	PJS: Joint and Survivor
013	PQD: Qualified Domestic Relations Order
014	PF: Fiduciary
015	PFB: Bankruptcy
016	PFC: Participant Contributions
017	PFE: Employer Contributions
018	PFN: Abandoned Plan
019	PFA: Administrative Fees
020	PFF: Fund Investment Fees
021	PFI: Investment of Funds
022	PFD: Default Investments
023	PFT: Prohibited Transaction
024	PGA: Plan General Administration
025	PB: Pension Benefits
026	PBE: Benefit Eligibility
027	PBD: Benefit Distributions
028	PBC: Pension Benefits, Can't Locate Plan
029	PBS: Pension Benefits, Social Security Notice
030	WRD: Reporting & Disclosure
031	WDD: Disclosure Requirements
032	WDR: Reporting Requirements
033	WF: Fiduciary
034	WFA: Administrative Fees
035	WFB: Bankruptcy
036	WFI: Paid Premiums/Insurance Cancelled
037	WFS: Self-Insured, No Funds
038	WGA: Plan General Administration
039	WWB: Welfare Benefits
040	WBE: Benefit Eligibility/Participating
041	WBP: Benefit Payments
042	WRC: Retiree Health
043	WCOBRA: COBRA
044	WCE: COBRA Eligibility
045	WCU: COBRA Under 20 Employees
046	WCN: COBRA Notices
047	WCD: COBRA Duration Coverage
048	WCP: COBRA Premiums
049	WCS: COBRA Successor Plans/Employer
050	WCI: COBRA Conversion to Individual Coverage
051	COBRA_CPA: COBRA Premium Assistance
052	WCX: General ARRA Assistance
053	WCC: COBRA Subsidy Denial
054	WHIPAA: HIPAA
055	WHP: HIPAA Pre-Existing Conditions
056	WHC: HIPAA Certificates of Creditable Coverage
057	WHS: HIPAA Special Enrollment Rights
058	WHD: HIPAA Discrimination/Health Status
059	WHG: HIPAA Group to Individual Policy
060	WHM: Mental Health Parity
061	WHN: Newborns' & Mothers' Act
062	WHW: Women’s Health & Cancer Rights Act
063	WRA: Health Reform Assistance
064	OTH: Other

# of Responses: 5

SM_1(501-503)

SM_2(504-506)

SM_3(507-509)

SM_4(510-512)

SM_5(513-515)

SN

QID:134513 REGION:

(Programmer: Code from fone file)

01	Atlanta and Miami (40 and 42)
02	Boston (31)
03	Chicago (50)
04	Cincinnati (43)
05	Dallas (63)
06	Kansas City (60)
07	Los Angeles (72)
08	New York (30)
09	Philadelphia and Washington DC (20 and 22)
10	San Francisco and Seattle (70 and 71)
11	National Office/OPA/DTAI (88)

SN(403-404)

SQ

QID:512331 OFFICE:

(Programmer: Code from fone file)

01	Atlanta (40)
02	Boston (31)
03	Chicago (50)
04	Cincinnati (43)
05	Dallas (63)
06	Kansas City (60)
07	Los Angeles (72)
08	Miami (42)
09	New York (30)
10	Philadelphia (20)
11	San Francisco (70)
12	Seattle (71)
13	Washington DC (22)

SQ(427-428)

SO

QID:134979 METHOD OF INQUIRY (CORRESPONDENCE_TYPE):

(Programmer: Code from fone file)

01	Telephone (T)
02	Routine Mail (M)
03	Web site (W)

SO(405-406)

SP

QID:153217 INITIAL DATE OF INQUIRY (INQUIRY START DATE):

(Programmer: Code from fone file)

SP(300-309)

SR

QID:134923 FORM

(Programmer: Randomly assign each respondent)

1	Form 1
2	Form 2

SR(2002)

SS

QID:13xxx LEFT MESSAGE

(Programmer: Code from fone file)

1	Waiting

SS(xxxxx)

(Interviewer: ASK TO SPEAK TO INQUIRER NAME FROM FONE FILE:)

INTRO1

QID:120821 Hello, this is __________, from The Gallup Poll. We are calling on behalf of the Employee Benefits Security Administration or EBSA (say: E-B-S-A) of the U.S. Department of Labor. Our records indicate that you recently contacted EBSA concerning a retirement, health, disability, or other employee benefits issue. We are conducting a very short poll about your interaction with this agency. It should take less than five minutes.

By law, I must inform you that the Paperwork Reduction Act requires Federal agencies to obtain Office of Management and Budget authorization before conducting any information collection, and persons are not required to respond to an information collection that is not currently approved. The Office of Management and Budget has authorized this survey for use through February 2019 under control number XXXXXXX
I want to assure you that Gallup and EBSA will protect your privacy. Your voluntary cooperation is requested to make the results of this study complete and accurate. Gallup will not share your individual responses with EBSA and your data will only be used in aggregate with responses of others like you.

1	Respondent available - (Continue)
4	No such person - (Thank and Terminate)
7	Respondent not available - (Set time to call back)
8	(Soft Refusal)
9	(Hard Refusal) - (Thank and Terminate)

INTRO1(2001)

(Programmer: All interviews are recorded. The recording begins when the respondent answers the phone. This statement is read after the "Continue" response is entered after the Introduction and before the first question.)

FRECCONS

QID:98881 This interview will be recorded for internal quality assurance.

1	(Continue)
2	(Refused) - (Thank and Terminate)

FRECCONS(1984)

S1

QID:134516 Do you recall communicating with the Employee Benefits Security Administration or EBSA? This probably would have occurred within the past few weeks. (If necessary, read:) Again, this agency is part of the Department of Labor and provides assistance to employees and beneficiaries regarding employee retirement, health, disability, and other employee benefit plans. EBSA oversees laws such as ERISA (say ur-RIS-uh), the Affordable Care Act, COBRA (say: CO-bruh) and HIPAA (say: HIP-uh).  

1	Yes
2	No
3	(DK)
4	(Refused)

S1(2011)

QID:135095 Skip: (If code 1 in S1, Continue;
Otherwise, Thank and Terminate)

(Interviewer: READ:)

QID:564262 Throughout the remainder of the survey, we will refer to the Employee Benefits Security Administration as EBSA.

CE1 HC - DB,CE - DB

QID:21495 Taking into account all the information, products, and services you receive from them, how satisfied are you with EBSA overall? Please use a five-point scale, where 5 means you are extremely satisfied and 1 means you are not at all satisfied. You may use any of the numbers 1, 2, 3, 4, or 5 for your rating.

1	Not at all satisfied
2
3
4
5	Extremely satisfied
7	(Not applicable)
8	(DK)
9	(Refused)

CE1(2101)

CE3 HC - DB,CE - DB

QID:21497 If a friend or a colleague had a similar need for information or assistance, how likely would you be to recommend EBSA? Please use a five-point scale, where 5 means extremely likely and 1 means not at all likely. You may use any of the numbers 1, 2, 3, 4, or 5.  

1	Not at all likely
2
3
4
5	Extremely likely
7	(Not applicable)
8	(DK)
9	(Refused)

CE3(2103)

(Interviewer: READ:)

QID:589137 Now, I am going to read a number of statements. Using a five-point scale, where 5 means you strongly agree and 1 means you strongly disagree, please tell me how much you agree or disagree with each statement as it applies to EBSA. You may use any of the numbers 1, 2, 3, 4, or 5 for your rating. How about (read CE5-CE10, as appropriate):

CE5 HC - DB,CE - DB

QID:21500 EBSA always delivers on what they promise.

1	Strongly disagree
2
3
4
5	Strongly agree
7	(Not applicable)
8	(DK)
9	(Refused)

CE5(2112)

CE6A HC - DB,CE - DB

QID:21501 EBSA always treats me fairly.

1	Strongly disagree
2
3
4
5	Strongly agree
7	(Not applicable)
8	(DK)
9	(Refused)

CE6A(2113)

CE8

QID:572144 I am proud to have used EBSA's services.

1	Strongly disagree
2
3
4
5	Strongly agree
7	(Not applicable)
8	(DK)
9	(Refused)

CE8(2104)

CE9A HC - DB,CE - DB

QID:21504 EBSA always treats me with respect.

1	Strongly disagree
2
3
4
5	Strongly agree
7	(Not applicable)
8	(DK)
9	(Refused)

CE9A(2115)

CE10

QID:572146 EBSA is the perfect federal agency for people with needs like mine.

1	Strongly disagree
2
3
4
5	Strongly agree
7	(Not applicable)
8	(DK)
9	(Refused)

CE10(2105)

Q1

QID:134520 Again using a five-point scale, where 5 means you strongly agree and 1 means you strongly disagree, please tell me how much you agree or disagree with each statement as it applies to EBSA. How about __________:

(Interviewer: read and rotate Q1A-Q1J, then read Q1K)

1	Strongly disagree
2
3
4
5	Strongly agree
7	(Not applicable)
8	(DK)
9	(Refused)

Q1A			QID:134521	EBSA treats me like a valued customer.	Q1A(2121)
Q1B			QID:134522	EBSA is willing to work with me to make sure my needs are met.	Q1B(2122)
Q1C			QID:134523	EBSA acts in a timely fashion.	Q1C(2123)
Q1D			QID:134524	EBSA does what it says it will do.	Q1D(2124)
Q1E			QID:134525	HOLD	Q1E(2125)
Q1F			QID:134526	EBSA is easy to reach.	Q1F(2126)
Q1G			QID:134527	The information I receive from EBSA is clear and easy to understand.	Q1G(2127)
Q1H			QID:134528	EBSA does its best to help me out.	Q1H(2128)
Q1I			QID:564264	EBSA thoroughly answers all of my questions.	Q1I(2129)
Q1J			QID:564265	EBSA is proactive in addressing my question or issue.	Q1J(2130)
Q1K			QID:564266	If you had a need to work with EBSA again in the future, you would want to interact with this same benefits advisor.	Q1K(2131)

QID:564268 Skip: (If code 1-4 in Q1K, Continue;
Otherwise, Skip to Q14A)

Q13

QID:564269 What could have the benefits advisor [(If necessary, read:) the person you talked with on the phone] have done differently to make you want to interact with them again if you needed help from EBSA?

(Interviewer: Open ended and code)

01	Other (list)
02	(DK)
03	(Refused)
04	HOLD
05	HOLD

List Other:Y

Q13(2201-2202)

Q13_T(8005)

Q14A

QID:564270 Were you referred to another person, agency, or company for you to follow up with to resolve your issue or question?

1	Yes
2	No
7	(Not applicable)
8	(DK)
9	(Refused)

Q14A(2205)

QID:572153 Skip: (If code 2, 7, 8, or 9 in Q14A, Skip to Note before Q2;
Otherwise, Continue)

Q14B

QID:564272 Please tell me whether or not each of the following happened during your referral.

(Interviewer: Read Q14BA-Q14BD)

1	Yes
2	No
7	(Not applicable)
8	(DK)
9	(Refused)

Q14BA			QID:564273	The referral phone number was a working number.	Q14BA(2211)
Q14BB			QID:564276	The EBSA representative made the call with you on the line.	Q14BB(2212)
Q14BC			QID:564274	The referral was to the right agency, organization, or person.	Q14BC(2213)
Q14BD			QID:564275	The referral resulted in an answer to your question or a resolution to your issue.	Q14BD(2214)

QID:572147 Skip: (If code 2 in SR, Skip to Q3;
Otherwise, Continue)

Q2

QID:135100 After your interaction with EBSA, did you feel (read 3-1)?

3	Much more knowledgeable about your benefits rights
2	Somewhat more knowledgeable about your benefits rights, or
1	Not any more knowledgeable about your benefits rights
7	(Not applicable)
8	(DK)
9	(Refused)

(Skip: All in Q2, Skip to Note before Q8)

Q2(2141)

Q3

QID:134530 Please rate your level of agreement with each of the following statements using a five-point scale, where 5 means you strongly agree and 1 means you strongly disagree. You may use any of the numbers 1, 2, 3, 4, or 5 for your rating. How about __________:

(Interviewer: read Q3A-Q3B)

1	Strongly disagree
2
3
4
5	Strongly agree
7	(Not applicable)
8	(DK)
9	(Refused)

Q3A			QID:134531	As a result of the interaction I had with EBSA, I feel better informed to protect my benefits in the future.	Q3A(2151)
Q3B			QID:134532	As a result of the interaction I had with EBSA, I feel my benefits are more secure.	Q3B(2152)

QID:213175 Skip: (If code 02 OR 03 in SO, Skip to Q8A;
Otherwise, Continue)

Q8

QID:134983 When you first contacted EBSA, did you speak with a benefits advisor right away, or did you leave a message to have someone return your call?

1	Spoke with a benefits advisor right away
2	Left a message
3	(Left a message and no one called me back—I called again)
8	(DK)
9	(Refused)

Q8A

QID:134988 When you first contacted EBSA, how long did it take them to respond?

(Interviewer: Open ended and code)

1	Responded the same day
2	Responded within one day
3	Responded within two days
4	Responded within three or more days
7	(Have not yet responded)
8	(DK)
9	(Refused)

Q8A(2187)

Q8B At any during a telephone conversation with EBSA, did you experience: (read A-E)

			Yes	No	(DK)	(Refused)
A	[xxxxxx]	unprofessional noises in the background (for example a dog barking or child talking)	1	2	8	9
B		Static on the line that came from EBSA’s end	1	2	8	9
C		Difficulty being heard by the benefits advisor	1	2	8	9
D		Difficulty hearing the benefits advisor	1	2	8	9
E		Other unprofessional experience	1	2	8	9

Q15

QID:564281 Did you access the EBSA website at any point in your inquiry process?

1	Yes
2	No
8	(DK)
9	(Refused)

Q15(2221)

QID:572155 Skip: (If code 2, 8, or 9 in Q15, Skip to Note before Q9;
Otherwise, Continue)

Q15A

QID:564283 Did you access the website (read 1-2)?

1	Before you called EBSA, or
2	During the time EBSA was handling your inquiry
8	(DK)
9	(Refused)

Q15A(2223)

QID:564284 Skip: (If code 2, 8, or 9 in Q15A, Skip to Q15C;
Otherwise, Continue)

Q15B

QID:564285 Did you use the website (read 1-4)?

1	To look for a phone number
2	To try to answer your question
3	To submit an inquiry, or
4	For some other reason
8	(DK)
9	(Refused)

Q15B(2225)

Q15C

QID:564286 Using a scale from one-to-five, with 1 being not at all helpful and 5 being very helpful, how helpful was the EBSA website?

1	Not at all helpful
2
3
4
5	Very helpful
7	(Not applicable)
8	(DK)
9	(Refused)

Q15C(2227)

QID:572149 Skip: (If code 2 in SR, Skip to Q10;
Otherwise, Continue)

Q9

QID:134594 In the future, would you prefer to contact EBSA (read and rotate 1-5)?

1	By phone
2	By email
3	By submitting an online form
4	Through live chat on the Internet
5	Through the mail
6	(Other)
7	(No preference)
8	(DK)
9	(Refused)

Q9(2189)

Q10

QID:134989 Was EBSA able to assist you with your questions, problem, or recovering the benefit?

1	Yes
2	No
3	(Still working on it/Not yet resolved)
4	(DK)
5	(Refused)

Q10(2191)

QID:564287 Skip: (If code 2 in Q10, Continue;
Otherwise, Skip to D1)

Q11

QID:134605 Why was EBSA not able to assist you with your question or problem?

(Interviewer: Read 06-10, then read 01)

01	Or some other reason (list)
02	(DK)
03	(Refused)
04	(No reason given)
05	HOLD
06	There were limitations because of the law
07	There were limitations because of the plan rules
08	The company has terminated the plan
09	The company went bankrupt
10	The EBSA representative did not understand your question or problem

List Other:Y

Q11(2193-2194)

Q11_T(8002)

QID:68754 DEMOGRAPHICS BEGIN HERE:

D1

QID:30962 GENDER:

(Interviewer: Code only; Do NOT ask)

1	Male
2	Female

D1(2301)

D3(2547)

AGE

QID:609934 Can you please tell me your age?

(Interviewer: Open ended and code actual age)

01	01-
96	96
97	97+
98	(DK)
99	(Refused)

D4(2449-2450)

D3

QID:xx Is the area where you live considered to be (read 1-3)

1	Urban
2	Suburban
3	Rural
8	(DK)
9	(Refused)

D3(2438)

D5

QID:142578 Are you of Hispanic, Latino, OR Spanish origin - such as Mexican, Puerto Rican, Cuban, or other Spanish origin?

1	Yes
2	No
3	(DK)
4	(Refused)

D5(2438)

(RACE)

D69

QID:610195 Which of the following describes your race? You may select one or more.

(Interviewer: Read 1-5)

(Programmer: Allow FIVE responses)

1	White
2	Black or African-American
3	Asian
4	American Indian or Alaska Native, or
5	Native Hawaiian or Pacific Islander
8	(DK)
9	(Refused)
0	(No more responses)

# of Responses: 5

D69_1(2439)

D69_2(2440)

D69_3(2441)

D69_4(2442)

Veteran

QID:610xxx Have you ever served on active duty in the U.S. Armed Forces, Reserves or National Guard?

1	Yes, on active duty now
2	Yes, on active duty in the past
3	No, never served in the military
4	Only on active duty for training in the Reserves or National Guard (Vol.)
8	(DK)
9	(Refused)

Disability

QID:610xxx Do you have any disabilities, such as any conditions that make it hard to see, hear, make decisions, or do your daily activities?

1	Yes
2	No
3	(DK)
4	(Refused)

D5(2438)

QLGBT

QID:610200 Do you think of yourself as (read 1-6)?

Interviewer note: you can stop and code as soon as the respondent gives an answer. You do not need to read all options.

1	Straight or heterosexual
2	Lesbian
3	Gay
4	Bisexual
5	Transgender
6	Other LGBT (VOL.) (Queer, Same-sex-loving, Pansexual)
8	(DK)
9	(Refused)

QLGBT(2446)

LANG

QID:xxxxx In which language do you prefer to read written documents? (open ended and code)

1. English

2. Arabic

3. Chinese (Traditional and Simplified)

4. French

5. Haitian Creole

6. Korean

7. Polish

8. Portuguese

9. Russian

10. Spanish

11. Tagalog

12. Vietnamese

13. Other (do not list)

D4

QID:610204 Just to make sure we talk to a broad range of people, can you tell me your total household annual income, before taxes? I will read you several categories and you can stop me when I get to the category that includes your income.

(Interviewer: Read 01-09)

(Interviewer: You can stop reading categories once the respondent tells you his/her income. If the respondent volunteers income level before you read the category, you may code appropriately and move to the next item, you do not need to continue to read categories.)

01	Under $20,000
02	$20,000-$25,999
03	$26,000-$29,999
04	$30,000-$35,999
05	$36,000-$39,999
06	$40,000-$49,999
07	$50,000-$75,999
08	$76,000-$99,999
09	$100,000 or more
98	(DK)
99	(Refused)

(Interviewer: THANK RESPONDENT BY SAYING:)

QID:229796 Again, this is _____, with Gallup. I would like to thank you on behalf of EBSA and Gallup for your time. Our mission is to "help people be heard" and your opinions are important to Gallup in accomplishing this.

FINTVID

QID:98976 INTERVIEWER I.D. #:

FINTVID(1571-1574)

US DOL EBSA CE3 2017 Q2_Outbound

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