1-on-1 Assistance Survey

One-on-One Assistance Survey
OMB Control Number: 0985-0057
Hello, I am trying to reach {insert respondent’s name}. Is {insert he/she} available?
Hi, {insert respondent’s name}. My name is {insert phone-bank caller’s name} and I am calling to ask some
questions about your experience receiving one-on-one assistance from the {insert Agency name}.
1.

Our records indicate that you spoke with {insert team member’s name}, from {Agency name}, in the
last several weeks to discuss Medicare. Is this correct?
a) Yes (go to #2)
b) No (go to #1a)

1a. Do you recall any interaction with someone from {insert Agency name}?
a) Yes (go to #2)
b) No (end the survey)
{insert Agency name} would like to learn more about the level of customer service you received, and has asked
my firm, CG Strategy, to administer this survey in order to keep your answers completely anonymous. We will
not reveal your name or other personal identifying information.
2.

Would you like to participate in this survey?
a) Yes (go to #3)
b) No (end the survey)

This survey collection has been approved by the Office of Management and Budget (OMB) and will expire on
{insert date}. The OMB Control Number for this survey is {insert number}. If you would like to comment on this
survey or confirm that this is a valid collection, please contact {insert name} from the Survey Team at {insert
phone number}.

[Instruction to survey respondent] For many of the questions in this survey, I will ask you to respond to a
statement. For each statement, you can answer Strongly Agree, Agree, Neither Agree Nor Disagree, Disagree, or
Strongly Disagree. I will read these five choices after each question, but if you know your answer before I finish
the list feel free to interrupt me and provide your answer.
3.

“I was able to find and contact {insert Agency name} in a timely fashion.” Do you . . . ?
a) Strongly Agree (go to #4)
b) Agree (go to #4)
c) Neither Agree nor Disagree (go to #4)
d) Disagree (go to #4)
e) Strongly Disagree (go to #4)

4.

Were you able to…. . . ?
a) Speak to someone immediately (go to #5)
b) Asked for contact information so someone could follow up with you later (go to #4a)

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One-on-One Assistance Survey
OMB Control Number: 0985-0057
4a. How long did it take someone from {insert Agency name} to follow-up with you?
a) Same day (go to #5)
b) Within one week (go to #5)
c) Within two weeks (go to #5)
d) Other (please specify ______________) (go to #5)
5.

“The information provided to me was accurate.” Do you . . . ?
a) Strongly Agree (go to #6)
b) Agree (go to #6)
c) Neither Agree nor Disagree (go to #6)
d) Disagree (go to #6)
e) Strongly Disagree (go to #6)

6.

“{insert Agency name} provided me with useful information.” Do you . . . ?
a) Strongly Agree (go to #7)
b) Agree (go to #7)
c) Neither Agree nor Disagree (go to #7)
d) Disagree (go to #6a)
e) Strongly Disagree (go to #6a)

6a. Please complete the following statement: “The information I received was not useful because: . . .”
a) I didn’t receive the information in time to use it (go to #8)
b) I didn’t trust the accuracy of the information I received (go to #7)
c) I couldn’t obtain answers to my questions (go to #7)
d) Other (please specify__________________) (go to #7)
7.

As a result of the information you received, did you take or do you plan to take action?
a) Yes (please specify__________________) (go to #8)
b) No (go to #8)
c) Don’t know/Not sure (go to #8)

8.

“Overall, I was satisfied with my interaction with {insert Agency name}.” Do you . . . ?
a) Strongly Agree (go to #9)
b) Agree (go to #9)
c) Neither Agree nor Disagree (go to #9)
d) Disagree (go to #9)
e) Strongly Disagree (go to #9)

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One-on-One Assistance Survey
OMB Control Number: 0985-0057
9.

“I would contact {insert Agency name} again for assistance.” Do you . . . ?
a) Strongly Agree (go to #10)
b) Agree (go to #10)
c) Neither Agree nor Disagree (go to #10)
d) Disagree (go to #10)
e) Strongly Disagree (go to #10)

10. “I would recommend {insert Agency name}’s service to others.” Do you . . . ?
a) Strongly Agree (go to #11)
b) Agree (go to #11)
c) Neither Agree nor Disagree (go to #11)
d) Disagree (go to #11)
e) Strongly Disagree (go to #11)

[Instruction to survey respondent] The next question doesn’t have an answer scale, so please provide any
thoughts you may have.

11. What could {insert Agency name} do to improve the service(s) they provided to you?
a) [open-ended]

[Instruction to survey respondent] Thank you for answering our questions about your experience with the
SHIP/SMP. We have four additional demographic questions to get a better sense of who we’re serving. Your
responses will not be shared individually with your name. They will be reported in a summary with many other
responses/answers. With each question, you have an option not to answer.

12. Which of the following race(s) best represent you? [Select ALL that apply]:
A American Indian or Alaskan Native
B Asian
C Black or African American
D Hispanic or Latino
E Native Hawaiian or Other Pacific Islander
F White
G Prefer not to answer
13. Which of the following best represents how you think of yourself? [Select ONE]:
A
B
C

Lesbian or gay
Straight, that is, not gay or lesbian
Bisexual

D
E
F

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I use a different term
________________________________
Don’t know
Prefer not to answer

One-on-One Assistance Survey
OMB Control Number: 0985-0057

14. What sex were you assigned at birth, on your original birth certificate?
A Female
B Male
C Don’t know
D Prefer not to answer
15. What is your current gender? [Select ONE]
A Female
B Male
C Transgender
D I use a different term ________________________________
E Don’t know
F Prefer not to answer

Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless such collection displays a valid OMB control number (OMB 0985-0057). Public reporting
burden for this collection of information is estimated to average six minutes per response, including time for
gathering and maintaining the data needed and completing and reviewing the collection of information. The
obligation to respond to this collection is voluntary.

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