Respondent Correspondence

ATTACHMENT B
RESPONDENT CORRESPONDENCE

ATTACHMENT B1
ADVANCE LETTER

SOCIAL SECURITY
Para información e instrucciones en español, llame por favor.
STANDARD INCENTIVE GROUP
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
We need your help with an important study by Social Security Administration, called the
National Beneficiary Survey (NBS). The NBS gathers information about the health and wellbeing of people who receive Social Security Disability Insurance (SSDI) or Supplemental
Security Income (SSI). The study will help us learn how well our programs meet the needs of
people like you.
Although taking part is your choice, your input will help make our programs better. Your answers
represent others like you all across the country, so your taking part is very important to the
success of the survey. We will use the answers you provide only for research. SSA will not
share your answers in any way that reveals who you are. SSA will not use your information to
make decisions about your disability benefits.
We have hired Mathematica Policy Research (Mathematica) for this survey. In about a week,
someone from Mathematica will call to speak with you. To thank you for your time,
Mathematica will send you a $20 gift card after you complete the interview.
If you want to set up a time to talk or need help to take part in the survey, please call
Mathematica at 888-888-8888 (toll-free) or send an email to insert@mathematica-mpr.com.
Mathematica’s TTY number is 888-888-8888.
To learn more about the NBS, please see the brochure included in this letter or log on to
www.insert.com.
We look forward to speaking with you. Thank you for your participation.
Sincerely,
David Weaver
Associate Commissioner
Office of Program Development and Research
Office of Retirement and Disability Policy

Privacy Act Statement
Collection and Use of Personal Information
Public Law 106-170 Section 101 (1)(d)(4)(C)(i), allows us to collect this information. We will use
your answers to learn more about disability beneficiaries, how well our programs are working,
and design new programs. The information will solely be used for research purposes to
improves SSA's programs and policies.
Participation is voluntary and participating or not participating will not affect your benefits.
We use the information you supply primarily for the purposes stated above. However, we may
use it for the administration and integrity of our programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include
but are not limited to the following:
1. To comply with Federal laws requiring the release of information from Social Security
records (e.g. to the Government Accountability Office and Department of Veterans
Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs, including responding to
questions from Congress.
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0058, Master Files of Social Security
Number (SSN) Holders and SSN Applications. Additional information about this and other
system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.

ATTACHMENT B2
SSA BROCHURE

The National Beneficiary Survey
What is the National Beneficiary Survey?

The National Beneficiary Survey is an important study by the Social Security
Administration. The study began in 2004 to collect information from people using Social
Security disability programs, including:
•
•
•
•
•

The programs and services they use
Their health and welfare
Their goals
Their education and training
Any support they need to work

This year, we are talking to people like you who receive (or used to receive) Social
Security Disability Insurance (DI) or Supplemental Security Income (SSI) to find out how
these programs are working for you.
As a thank you, Mathematica will send you a $20 gift card after you finish the interview.
The $20 gift card does not count as income and since it is received only once, is not
included in calculating the benefits of SSI recipients.

What have we learned from this survey so far?

Policymakers, researchers, and program staff use the information from the survey to
understand the issues people face in trying to work and live more independently. It also
helps us to make our programs work better for people with disabilities.
Here are some of the things we have learned from this survey in the past:
•
•

•
•

Most people are not aware of Social Security programs that can help them
live more independently or work.
People use many different support services to help them live on their own or
work (like special equipment and counseling and occupational therapy, job
training and job-search assistance).
1 out of 10 people said they are not receiving services that they need.
Even with health problems, many people in Social Security programs want to
work: 4 out of 10 people we surveyed in 2010 said they had work goals or
saw themselves working within the next five years.

How long will the interview take?

The interview will take about 45 minutes. We can do the interview at a time that is best
for you, and you can complete the interview in more than one phone call.

Why did you choose me?

We picked you by chance from a list of people who receive or used to receive Social
Security disability benefits. You represent other people like yourself across the country,
so your taking part in this survey is important to its success. Also, because we picked
you by chance, we cannot replace you with anyone else.

How do I take part?

We have hired a company, Mathematica Policy Research, to do this survey for us. An
interviewer will call you to ask you to participate. If you cannot do a phone interview, we
can use a teletypewriter (TTY), telecommunications relay service (TRS), video relay
(VRS), or instant messaging service (such as AIM). We can also do the interview in
Spanish or provide an interpreter if you speak another language. In most parts of the
country, we can send an interviewer to your home to speak to you in person. Your
participation is important to us.
You do not have to do the interview at all. If you do the survey, you can refuse to
answer any question you do not want to answer.
Note: The interviewer will never ask for your social security number.

Who can I contact with questions?

If you want to do the interview now, have questions, or need help, you can call
Mathematica Policy Research toll free at . You can send questions
or updated contact information to .
You can also write to us at:
National Beneficiary Survey
Mathematica Policy Research
1100 1st Street, NE, 12th Floor, Washington, DC 20002-4221
Website: www.mathematica-mpr.com
[twitter logo] MathPolResearch
[facebook logo] Facebook
Mathematica logo goes here

For more information about the survey, please visit our website:
http://www.ssa.gov/disabilityresearch/nbs.html

ATTACHMENT B3
REMINDER POSTCARD

We have good news! You have been chosen to participate in an important
health survey for the Social Security Administration. After you complete
the survey, we will send you a $20 Target or Walmart gift card – you get to
choose.
CALL 1-800-XXX-XXXX

COMPLETE SURVEY

GET $20 GIFT CARD

$20

Interviewers are available Monday thru Thursday from 9 a.m.-12 a.m.,
Friday from 9 a.m. to 10 p.m., Saturday from 9 a.m. to 8 p.m., and Sunday
from 1 p.m. to 9 p.m. (Eastern Time). We look forward to talking to you.

ATTACHMENT B4
SSA REMINDER LETTER

SOCIAL SECURITY
Para información y instrucciones en Español, llame por favor.
Date
NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear :
We recently sent you a letter about an important Social Security Administration (SSA)
study, the National Beneficiary Survey (NBS). The NBS gathers information about the health
and well-being of people who receive Social Security Disability Insurance (SSDI) or
Supplemental Security Income (SSI).
If you have already taken part in the survey, please accept my thanks. If not, please do
so today. We have hired Mathematica Policy Research, a national research firm, to conduct this
study for us. You can call Mathematica toll-free at 888-888-8888 or send an email to
insert@mathematica-mpr.com to take part in the survey. Mathematica’s TTY number is 888888-8888. After your interview, Mathematica will send you a $20 gift card to thank you.
Although taking part is your choice, your input will help make our programs better. Your
answers will be kept private. They will not be shared in any way that reveals who you are. SSA
will only use your information for research purposes. Your responses will not be used to make
decisions about your benefits.
Your participation is very important to us. To learn more about this study, please see the
answers to frequently asked questions included in this mailing or log onto www.insert.com.
Thank you very much for your time. We look forward to hearing from you.
Sincerely,
David Weaver
Associate Commissioner
Office of Program Development and Research
Office of Retirement and Disability Policy

Privacy Act Statement
Collection and Use of Personal Information
Public Law 106-170 Section 101 (1)(d)(4)(C)(i), allows us to collect this information. We will use
your answers to learn more about disability beneficiaries, how well our programs are working,
and design new programs. The information will solely be used for research purposes to
improves SSA's programs and policies.
Participation is voluntary and participating or not participating will not affect your benefits.
We use the information you supply primarily for the purposes stated above. However, we may
use it for the administration and integrity of our programs. We may also disclose information to
another person or to another agency in accordance with approved routine uses, which include
but are not limited to the following:
1. To comply with Federal laws requiring the release of information from Social Security
records (e.g. to the Government Accountability Office and Department of Veterans
Affairs);
2. To facilitate statistical research, audit, or investigative activities necessary to assure the
integrity and improvement of Social Security programs, including responding to
questions from Congress.
A complete list of when we may share your information with others, called routine uses, is
available in our Privacy Act System of Records Notice 60-0058, Master Files of Social Security
Number (SSN) Holders and SSN Applications. Additional information about this and other
system of records notices and our programs is available from our Internet website at
www.socialsecurity.gov or at your local Social Security office.

ATTACHMENT B5
REFUSAL CONVERSION LETTERS

1100 1st Street, NE, 12th Floor
Washington, DC 20002-4221
Telephone (202) 484-9220
Fax (202) 863-1763
www.mathematica-mpr.com

CONVERSION LETTER – GENERIC
Por favor vea el reverso para Español.

NAME
ADDRESS 1
ADDRESS 2
CITY, ST ZIP
Dear NAME:
We recently called to ask for your help with a study about the health and well-being of people who
receive Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). This study is
called the National Beneficiary Survey. When we called, we were not able to speak with you. I am writing
today to ask you to again consider taking part in this important study.
You probably receive a lot of phone calls from people trying to sell you things. This was not one of
those calls. The survey is funded by the Social Security Administration (SSA) and is being carried out by
Mathematica Policy Research. Results from the survey will help SSA learn how well its programs are
meeting the needs of people like you.
It is vital for us to hear from you so that SSA can improve its programs. This is your chance to tell us
what you think and to make your voice heard. Many people find the questions interesting and enjoy the
interview.
It is important that we talk to people with diverse experiences and backgrounds so that the results of this
study will represent the experiences of all current and past SSI and SSDI beneficiaries. We need your help
to make this study a success. If you have any questions about taking part or would like to speak with an
interviewer, please call us toll-free at 888-888-8888. You may also contact me directly at (202) 554-7576. I
would be happy to answer any questions you have. As our way of saying thanks, we will send you a $20
gift card after you complete the interview.
One of our interviewers will contact you within the next few weeks. I sincerely hope that you will
choose to participate.
Sincerely,
Associate Director of Survey Research

An Affirmative Action/Equal Opportunity Employer

1100 1st Street, NE, 12th Floor
Washington, DC 20002-4221
Telephone (202) 484-9220
Fax (202) 863-1763
www.mathematica-mpr.com

CONVERSION LETTER – CONFIDENTIALITY
Por favor vea el reverso para Español.
FLESCH KINCAID 8.6

NAME
ADDRESS 1
ADDRESS 2
CITY, ST ZIP
Dear NAME:

We recently called to ask for your help with a study about the health and well-being of people who
receive Social Security Disability Insurance (SSI) or Supplemental Security Income (SSDI). This study is
called the National Beneficiary Survey. When we called, we were not able to speak with you. I am writing
today to ask you to again consider taking part in this important study.
You probably receive a lot of phone calls from people trying to sell you things. This was not one of
those calls. The survey is funded by the Social Security Administration (SSA) and is being carried out by
Mathematica Policy Research. Results from the survey will help SSA learn how well its programs are
meeting the needs of people like you.
When we called, you said that you were concerned about the privacy of your answers. I assure you that
your answers will be kept private and will not be shared in any way that reveals who you are. Protecting
your privacy is one of our main concerns. During the interview, if there is a question you do not want to
answer, just ask the interviewer to skip it.
It is important that we talk to people with diverse experiences and backgrounds so that the results of this
study will represent the experiences of all current and past SSI and SSDI beneficiaries. We need your help
to make this study a success. If you have any questions about taking part or would like to speak with an
interviewer, please call us toll-free at . You may also contact me directly at . I would
be happy to answer any questions you have. As our way of saying thanks, we will send you a $20 gift card
after you complete the interview.
One of our interviewers will contact you within the next few weeks. I sincerely hope that you will
choose to participate.
Sincerely,
Associate Director of Survey Research

An Affirmative Action/Equal Opportunity Employer

1100 1st Street, NE, 12th Floor
Washington, DC 20002-4221
Telephone (202) 484-9220
Fax (202) 863-1763
www.mathematica-mpr.com

CONVERSION LETTER – NO DIFFERENCE
Por favor vea el reverso para Español.
FLESCH KINCAID 8.4

NAME
ADDRESS 1
ADDRESS 2
CITY, ST ZIP
Dear NAME:

We recently called to ask for your help with a study about the health and well-being of people who
receive Social Security Disability Insurance (SSI) or Supplemental Security Income (SSDI). This study is
called the National Beneficiary Survey. When we called, we were not able to speak with you. I am writing
today to ask you to again consider taking part in this important study.
You probably receive a lot of phone calls from people trying to sell you things. This was not one of
those calls. The survey is funded by the Social Security Administration (SSA) and is being carried out by
Mathematica Policy Research. Results from the survey will help SSA learn how well its programs are
meeting the needs of people like you.
When we called, you told us that you think this study will not make much of a difference. However, the
answers you and others give will be used by SSA to learn about the experiences and needs of people who
are receiving (or used to receive) disability benefits. This is your chance to tell us what you think and to
make your voice heard. Your input will help SSA improve its programs for people like you.
It is important that we talk to people with diverse experiences and backgrounds so that the results of this
study will represent the experiences of all current and past SSI and SSDI beneficiaries. We need your help
to make this study a success. If you have any questions about taking part or would like to speak with an
interviewer, please call us toll-free at . You may also contact me directly at . I would
be happy to answer any questions you have. As our way of saying thanks, we will send you a $20 gift card
after you complete the interview.
One of our interviewers will contact you within the next few weeks. I sincerely hope that you will
choose to participate.
Sincerely,

Associate Director of Survey Research

An Affirmative Action/Equal Opportunity Employer

1100 1st Street, NE, 12th Floor
Washington, DC 20002-4221
Telephone (202) 484-9220
Fax (202) 863-1763
www.mathematica-mpr.com

CONVERSION LETTER – NOT INTERESTED
Por favor vea el reverso para Español.
FLESCH KINCAID 8.6

NAME
ADDRESS 1
ADDRESS 2
CITY, ST ZIP
Dear NAME:
We recently called to ask for your help with a study about the health and well-being of people who
receive Social Security Disability Insurance (SSI) or Supplemental Security Income (SSDI). This study is
called the National Beneficiary Survey. When we called, we were not able to speak with you. I am writing
today to ask you to again consider taking part in this important study.
You probably receive a lot of phone calls from people trying to sell you things. This was not one of
those calls. The survey is funded by the Social Security Administration (SSA) and is being carried out by
Mathematica Policy Research. Results from the survey will help SSA learn how well its programs are
meeting the needs of people like you.
When we called, you told us that you were not interested in taking part in the survey. It is vital for us to
hear from you so that SSA can improve its programs for people who are receiving (or used to receive)
disability benefits. This is your chance to tell us what you think and to make your voice heard. Many people
find the questions interesting and enjoy the interview.
It is important that we talk to people with diverse experiences and backgrounds so that the results of this
study will represent the experiences of all current and past SSI and SSDI beneficiaries. We need your help
to make this study a success. If you have any questions about taking part or would like to speak with an
interviewer, please call us toll-free at . You may also contact me directly at . I would
be happy to answer any questions you have. As our way of saying thanks, we will send you a $20 gift card
after you complete the interview.
One of our interviewers will contact you within the next few weeks. I sincerely hope that you will
choose to participate.
Sincerely,

Associate Director of Survey Research
An Affirmative Action/Equal Opportunity Employer

1100 1st Street, NE, 12th Floor
Washington, DC 20002-4221
Telephone (202) 484-9220
Fax (202) 863-1763
www.mathematica-mpr.com

CONVERSION LETTER – TOO LONG
Por favor vea el reverso para Español.
FLESCH KINCAID 8.3

NAME
ADDRESS 1
ADDRESS 2
CITY, ST ZIP
Dear NAME:

We recently called to ask for your help with a study about the health and well-being of people who
receive Social Security Disability Insurance (SSI) or Supplemental Security Income (SSDI). This study is
called the National Beneficiary Survey. When we called, we were not able to speak with you. I am writing
today to ask you to again consider taking part in this important study.
You probably receive a lot of phone calls from people trying to sell you things. This was not one of
those calls. The survey is funded by the Social Security Administration (SSA) and is being carried out by
Mathematica Policy Research. Results from the survey will help SSA learn how well its programs are
meeting the needs of people like you.
When we called, you told us that you thought the interview would take too long. Your input is
important, however, and we want to work with you to make sure your voice is heard. We can set up the
interview for a time that works for you. We can also complete the interview in more than one call. If you
begin to feel tired or are not feeling well enough to be interviewed, we will call you back to continue the
interview another time.
It is important that we talk to people with diverse experiences and backgrounds so that the results of this
study will represent the experiences of all current and past SSI and SSDI beneficiaries. We need your help
to make this study a success. If you have any questions about taking part or would like to speak with an
interviewer, please call us toll-free at . You may also contact me directly at . I would
be happy to answer any questions you have. As our way of saying thanks, we will send you a $20 gift card
after you complete the interview.
One of our interviewers will contact you within the next few weeks. I sincerely hope that you will
choose to participate.
Sincerely,
Associate Director of Survey Research

An Affirmative Action/Equal Opportunity Employer

1100 1st Street, NE, 12th Floor
Washington, DC 20002-4221
Telephone (202) 484-9220
Fax (202) 863-1763
www.mathematica-mpr.com

CONVERSION LETTER – TOPIC OR ORGANIZATION
Por favor vea el reverso para Español.
FLESCH KINCAID 8.3

NAME
ADDRESS 1
ADDRESS 2
CITY, ST ZIP
Dear NAME:

We recently called to ask for your help with a study about the health and well-being of people who
receive Social Security Disability Insurance (SSDI) or Supplemental Security Income (SSI). This study is
called the National Beneficiary Survey. When we called, we were not able to speak with you. I am writing
today to ask you to again consider taking part in this important study.
You probably receive a lot of phone calls from people trying to sell you things. This was not one of
those calls. The survey is funded by the Social Security Administration (SSA) and is being carried out by
Mathematica Policy Research. Results from the survey will help SSA learn how well its programs are
meeting the needs of people like you.
When we called, you told us that you did not want to take part in a study for SSA. This is your chance
to tell us what you think and to make your voice heard. It is vital for us to hear from you so that SSA can
learn about the experiences and needs of people who are receiving (or used to receive) disability benefits.
Your input will help SSA improve its programs for people like you. I also want to assure you that your
answers will be reported in a way that does reveal who you are to SSA.
It is important that we talk to people with diverse experiences and backgrounds so that the results of this
study will represent the experiences of all current and past SSI and SSDI beneficiaries. We need your help
to make this study a success. If you have any questions about taking part or would like to speak with an
interviewer, please call us toll-free at . You may also contact me directly at . I would
be happy to answer any questions you have. As our way of saying thanks, we will send you a $20 gift card
after you complete the interview.
One of our interviewers will contact you within the next few weeks. I sincerely hope that you will
choose to participate.
Sincerely,
Associate Director of Survey Research

An Affirmative Action/Equal Opportunity Employer

ATTACHMENT B6
LOCATING LETTER

1100 1st Street, NE, 12th Floor
Washington, DC 20002-4221
Telephone (202) 484-9220
Fax (202) 863-1763
www.mathematica-mpr.com

Por favor vea el reverso para Español.

Dear NAME:

We need your help with an important Social Security Administration (SSA) study: the
National Beneficiary Survey (NBS). The NBS gathers information about the health and wellbeing of people who receive Social Security Disability Insurance (SSDI) or Supplemental
Security Income (SSI). The study will help SSA learn how well its programs meet the needs of
people like you. SSA has hired Mathematica Policy Research to conduct this study.
We would like to interview you for the study, but we do not have your current phone
number. Although taking part in the study is your choice, your input is important and will help
make SSA programs better. It is vital that we talk to people with a wide range of experiences and
backgrounds. To thank you for your time, we will send you a $20 gift card after you
complete the interview.
Your information will be kept private and will not be shared in any way that reveals who
you are. SSA will only use your information for research purposes. Your responses will not be
used to make decisions about your benefits.
Please call us toll-free at 888-888-8888 to set up a time to be interviewed. You can also
contact us by sending an email with your name and telephone number to insert@mathematicampr.com. Our TTY number is 888-888-8888.
Thank you for your time. We look forward to hearing from you.
Sincerely,
Associate Director of Survey Research

An Affirmative Action/Equal Opportunity Employer

ATTACHMENT B7
PREPAY LETTER

1100 1st Street, NE, 12th Floor
Washington, DC 20002-4221
Telephone (202) 484-9220
Fax (202) 863-1763
www.mathematica-mpr.com

Por favor vea el reverso para Español.

FIRST NAME LAST NAME
ADDRESS 1
ADDRESS 2
CITY, STATE ZIP
Dear FIRST NAME:
I am writing to ask for your help with an important Social Security Administration (SSA)
study, the National Beneficiary Survey (NBS). The NBS gathers information about the health and
well-being of people who receive Social Security Disability Insurance (SSDI) or Supplemental
Security Income (SSI).
SSA has hired us, Mathematica Policy Research, to interview people for this study. We are a
national research firm that conducts surveys for federal, state, and local governments on important
policy issues. We have tried calling you, but have not been able to reach you. While taking part is
your choice, your participation is very important and will help SSA make their programs better.
Your information will be kept private and will not be shared in any way that identifies you. SSA
will only use your information for research purposes. Your responses will not be used to make
decisions about your benefits.
In about one week, an interviewer from Mathematica will visit you at your home to make it
easier for you to take part in this important survey. To thank you in advance for taking part, we
have included a $5 gift card with this letter. We will give you another $15 gift card after you
complete the interview.
Taking part in this survey is easy. Just call us toll-free at 888-888-8888 to complete the survey
by telephone or to set up a time to be interviewed. You can also send us an email with your name
and telephone number to insert@mathematica-mpr.com. Our TTY number is 888-888-8888.
Thank you for your participation. We need your help to make this study a success.
Sincerely,
Associate Director of Survey Research

An Affirmative Action/Equal Opportunity Employer

ATTACHMENT B8
FIELD LOCATING LETTER

1100 1st Street, NE, 12th Floor
Washington, DC 20002-4221
Telephone (202) 484-9220
Fax (202) 863-1763
www.mathematica-mpr.com

Por favor vea el reverso para Español.

_____________
(DATE)

Dear ____________________:
We have been trying to reach you about an important study funded by the Social
Security Administration (SSA): the National Beneficiary Survey (NBS). SSA has hired us,
Mathematica Policy Research, to conduct this survey.
We would like you to take part in the survey, but we have not been able to reach you.
Although taking part is your choice, your input is very important and will help SSA make
their programs better. You should already have received a $5 gift card to thank you in
advance for taking part. We will send you another gift card for $15 after you complete
the interview.
Your information will be kept private and will not be reported in any way that reveals
who you are. We will use this information for research purposes only.
Please call us toll-free at 888-888-8888 (888-888-8888 for TTY) to take part in the
survey or to set up a time to be interviewed. You can also send an email with your name
and telephone number to insert@mathematica-mpr.com.
Thank you for your time. We hope you will help us make this study a success.
Sincerely,

Associate Director of Survey Research

ATTACHMENT B9
SORRY CARD

“Sorry I Missed You” Card
Sorry I missed you!
My name is _______________, and I’m with Mathematica Policy Research.
I stopped by to speak with you about an important national health survey.
To complete the survey, please call our toll-free number, 888-888-8888 (or
888-888-8888 for TTY).
As our way of saying thanks, we will give you a $20 gift card for taking part
in the survey.
Thank you! I hope to hear from you soon.

ATTACHMENT B10
POSTMASTER LETTER

UNITED STATES SOCIAL SECURITY ADMINISTRATION
Washington, DC 20202
TO: POSTMASTER

DATE:
ADDRESS INFORMATION REQUEST

Please provide Mathematica Policy Research, or an authorized representative of Mathematica, with the new address of the following
individual, or verify whether the address given below is where mail for this individual is currently being delivered. If the following
address is a post office box, please furnish the street address as recorded on the box holder’s application form.
Old name and address:

I certify that Mathematica is under contract to the Social Security Administration to conduct a survey that will help the government
evaluate and manage its disability programs. The individual listed above was chosen at random for the survey. The address
information for this individual is required for the performance of Mathematica’s official duties.
Information about this study is available at http://www.socialsecurity.gov/disabilityresearch/research.htm#nbs.
Elaine Gilby, Ph.D., Economist
U.S. Social Security Administration, 500 E Street, SW, 9th floor, Washington, DC 20024-2796
Elaine.Gilby@ssa.gov
(202) 358-6449
Please return this form to:

Mathematica Policy Research
Attn:
707 Alexander Road
Building 3, Suite 304
Princeton, NJ 08540
Fax: (609) 936-1462

FOR POST OFFICE USE ONLY
( ) MAIL IS DELIVERED TO ADDRESS GIVEN

NEW ADDRESS:

( ) NOT KNOWN AT ADDRESS GIVEN
( ) MOVED, LEFT NO FORWARDING ADDRESS
( ) NO SUCH ADDRESS

BOX HOLDER’S STREET ADDRESS:

( ) DECEASED, DATE:
( ) OTHER (SPECIFY): _______________________________ POST OFFICE REPRESENTATIVE:
The name and address of the individual for which information is sought has been provided by
Mathematica. This information and any information provided by the USPO will be held in strict
confidence by Mathematica and the Social Security Administration.

ATTACHMENT B11
HIPAA LETTER

1100 1st Street, NE, 12th Floor
Washington, DC 20002-4221
Telephone (202) 484-9220
Fax (202) 863-1763
www.mathematica-mpr.com

REPRESENTATIVE NAME
ORGANIZATION
ADDRESS
CITY, STATE ZIP
Dear NAME:

Thank you for your interest in the National Beneficiary Survey (NBS). Let me take a moment to tell
you more about the study and why we would like to interview
. The NBS is an important study funded by the Social Security
Administration (SSA) to collect information about the programs and services used by people with
disabilities. The survey asks about their health and well-being and about their experiences in finding and
keeping a job. The NBS is being conducted to help SSA assess how well its programs are meeting the needs
of past and current beneficiaries.
was randomly selected to
take part in this study. Although ’s cooperation is voluntary, we
would greatly appreciate help.
As a contractor to SSA, Mathematica Policy Research is conducting the NBS, a function that is
classified as a “public health authority action.” This allows us to access protected health information (PHI)
under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule [45 CFR 160-164].
Although this classification permits access to PHI without a waiver from an institutional review board or
privacy board, and it does not require individual authorization to obtain PHI, I want to assure you that
Mathematica follows the strict standards specified by HIPAA for collecting health information for research
purposes. It is Mathematica’s policy that any information provided by research participants will be kept
strictly confidential. Furthermore, SSA will not use the information to make any decisions about a
participant’s receipt of disability benefits. We are collecting this information for research purposes only.
We would like to interview by telephone. This interview will
take 45 to 60 minutes to complete. As a token of our appreciation, Mathematica will send a gift card for $20 after completes the interview. If is unable to participate, we may be able to interview someone on
behalf who is familiar with health, education, and experience with SSA programs.
If you have questions about this study or ’s
participation, please call us toll-free at or send an email to . To learn more about this
study, you can also visit SSA’s website at www.socialsecurity.gov/disabilityresearch/research.htm#nbs.
Thank you for your assistance.
Sincerely,
Associate Director of Survey Research

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