Attachment A-20. Pre-collection instrument

Appendix A-21. Pre-Collection Questions

INITIAL WEB LOG IN SCREEN:
Please sign in. Enter your Access Code to begin.
ACCESS CODE:_______________
Privacy Act Statement
Collection and Use of Personal Information
Section 1110(a) of the Social Security Act, as amended, allows us to collect this information, which we
will use to help the Social Security Administration (SSA) identify ways to help people who may be leaving
or have left disability programs. Providing us this information is voluntary; not providing all or part of
the information will not affect your SSA benefit. As law permits, we may use and share the information
you submit, including with other Federal agencies, contractors, student volunteers, and others, as
outlined in the routine uses within System of Records Notice (SORN) 60-0218, available at
www.ssa.gov/privacy. The information you submit may also be used in computer matching programs to
establish or verify eligibility for Federal benefit programs and to recoup debts under these programs.
S1.

Please confirm that your name is [NAME]?



Yes  (GO TO INTRO1)
No  (GO TO END)

[INTRO1]
The Social Security Administration is conducting this study and Westat is supporting them. We recently
[mailed/emailed] you a letter about the study along with a consent form and other documents. We
hope you have had a chance to read through them and will agree to participate in the study.
S2.

First, please confirm that you received the materials and do not have any questions about the
materials we sent to you?




S3.

I received the materials and do NOT have any questions  (GO TO S4)
I received the materials and DO have any questions  (GO TO END2)
I did not receive the materials

Would you like us to mail you a copy of the study invitation letter and other documents?



Yes  (GO TO S3A)
No  (GO TO S4)

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Appendix A-21. Pre-Collection Questions

S3a.

Please confirm the mailing address we have for you is correct.
Is your address: DISPLAY ADDRESS ON FILE?



Yes  (GO TO S4)
No  (GO TO S3B)

S3b.

Where would you like us to mail the study invitation letter and other documents?

S4.

CONSENT: Please review the consent form that we sent to you in the mail:
The purpose of this research is to help SSA identify ways to help people who may be leaving or
have left disability benefit programs. Please remember that it is your choice whether to
participate in this study. Your participation will contribute to SSA’s understanding of policies and
programs that might be helpful to people who leave disability programs. 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 your current or future SSA application for benefits. The information
we collect is used for research in limited ways. Nothing in the study will directly benefit
you. Hopefully, it will benefit future SSI and SSDI beneficiaries leaving disability benefit
programs.

STREET NUMBER:_________________ STREET NAME:___________________________________
CITY:________________________ STATE: _________________ ZIP: ______________

The [interview/focus group/survey] will take about X 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?
 Yes
 No  (GO TO THANK)

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Appendix A-21. Pre-Collection Questions

S5.

May I please have your email address to communicate important study information with you?



S6.

Do you have a cell phone that we can send text reminder messages about the study?



S7.

Yes  RECORD EMAIL ADDRESS TWICE
No  (GO TO S7)

Yes
No  (GO TO S8)

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

S8.

FOCUS GROUP RESPONDENTS ONLY: The focus group will be recorded to help with note-taking.
You do not have to use your real name and you can choose to turn your camera on or off during
the virtual focus group. In order to participate in the focus group, we need your consent for the
focus group to be recorded. Do you consent to the recording of the focus group?



S9.

Yes
No  (GO TO END3)

After you have completed the [SURVEY/INTERVIEW/FOCUS GROUP], we will mail you a pre-paid
Visa gift card in the amount of $[AMOUNT].
Please confirm the address we have for you is correct.
[DISPLAY ADDRESS].



S10.

Would you like to provide the correct mailing address where we can mail your pre-paid Visa gift
card when you are done with [THE SURVEY/INTERVIEW/FOCUS GROUP]?



S11.

This is the correct address  (GO TO S11)
No, this is not the correct address  (GO TO S10)

Yes, I will give my address  (GO TO S11)
No, I do not want to give my address but I will still participate  (GO TO S12)

What is your mailing address?
STREET 1:___________________________
STREET 2:______________________________
CITY:_____________________________ STATE:_______________ZIPCODE:_____________

S12. Please select [an interview/a focus group] from the list of date and times available below.
LIST ALL AVAILABLE TIME SLOTS FOR INTERVIEW/FOCUS GROUP  (GO TO CONFIRMATION PAGE)

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Appendix A-21. Pre-Collection Questions

CONFIRMATION PAGE:
You are now scheduled for (an interview/a focus group) on [DATE] at [TIME]. Please give us a call at 1855-3665 if you have any questions or need to reschedule. (GO TO THANK)

END1: I am sorry, but you are not eligible for this survey. Have a nice day.
END2: If you have questions and would like to talk to a study researcher before proceeding, please call
the Beyond Benefits Study Help Desk at 1-855-516-3665.
END3: I am sorry but in order to participate in the focus group, we must have your permission to record
the group. Those are all the questions we have. Have a nice day.
THANK: Thank you for your time answering these questions. Have a nice day.

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