Fiscal Year (FY) 2017 Office Visitor Survey (OVS)/

FY 17 HPRC AWARD SURVEY - ENGLISH

Hearings Process Report Card Survey
Social Security is continually working to improve the service we provide to the public. Please complete
this questionnaire to give us your opinion of the service you received when you requested a hearing on
your application for disability benefits.
MARKING INSTRUCTIONS
Correct Marking Example: 

 Use blue or black pen or a number 2 pencil.
 Make no stray marks.
 Do not use pens with ink that soaks through the  Keep all entries within the boxes.
paper.

Please use the scale shown to rate the following aspects of your hearing experience.

Not
Applicable



Very Poor

Good



Poor

Very Good



Fair

Excellent

Mark [X] ONE answer for every item. If a question does not apply to you, please mark Not Applicable.

When you decided to request a hearing…
1.

Ease of finding information about how to file
your hearing request

  




2.

Quality of information you got from Social
Security explaining the hearing process







  









  



While you were waiting for your hearing to be held…
3.

Ease of contacting Social Security about your
hearing request


4.

Helpfulness of the information Social Security
gave you about your hearing request







  

How your hearing was held…
5. Did you have a representative, either an attorney or some other person, handle your hearing?
Mark only ONE answer.

Yes
No
6.

Did you have a hearing with a judge face-to-face or by video conference?
Mark only ONE answer.

Hearing was face-to-face with a judge.
Hearing was by video conference with a judge.
No hearing was held with a judge.

 Please continue with question 7
 Please continue with question 7
 Please continue with question 14

PLEASE CONTINUE TO PAGE 2



Very Good

Good

Poor

Very Poor

Not
Applicable

7.

Location of the office where your hearing was
held







 





8.

How well the judge explained what would
happen at your hearing







 





9.

How prepared the judge was to talk about the
facts of your case







 





10. Opportunity the judge gave you or your
representative to present the facts of your case







 





11. Courtesy of the judge







 





12. Length of time from the date you first
requested your hearing until it was held







 





13. Length of time from the date your hearing was
held until you received the decision







 





14. Overall length of time from the date you first
requested your hearing until you received the
decision







 





Fair

Excellent

Please use the scale shown to rate the following aspects of your hearing experience.
Mark [X] ONE answer for every item

When your hearing was held…

Waiting for the hearing and decision…















Notice of Social Security’s decision on your hearing…
15. How well the notice explained the decision on
your hearing







 





16. How well the notice explained the amount of
your benefits and when they would start







 





17. Helpfulness of the staff







 





18. Courtesy of the staff







 





19. How well the staff knew their jobs







 





20. Overall experience with the hearing on your
disability application







 





21. Overall opinion of Social Security’s service







 





Your overall experience with Social Security…

A little more about you…
22.
When you do business with Social Security, in person, on the telephone, or online, do you need
them to provide any special accommodations because of a medical condition?
Mark [X] ONE answer.
 Yes
 No  SKIP to Question 25.
23. Do you need special accommodations because of a:
Mark [X] all that apply.
 Physical limitation (for example, wheelchair access)
 Visual limitation (for example, large print or Braille documents)
 Deafness or difficulty hearing (for example, sign language interpreter or video relay)
 Other limitation (for example, a learning disability)
24. How satisfied are you with how well Social Security meets your need for special accommodations?
Are you:
Mark [X] ONE answer.
 Very satisfied
 Somewhat satisfied
 Somewhat dissatisfied, or
 Very dissatisfied
25. Please use this space to explain any of your answers, especially any reasons for dissatisfaction, or to
provide any other comments about the service you received in connection with your hearing.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
OMB Control Number 0960-0526, Expiration Date: TBD

FY 17 HPRC DENIAL SURVEY - ENGLISH

Hearings Process Report Card Survey
Social Security is continually working to improve the service we provide to the public. Please complete
this questionnaire to give us your opinion of the service you received when you requested a hearing on
your application for disability benefits.
MARKING INSTRUCTIONS
Correct Marking Example: 

 Use blue or black pen or a number 2 pencil.
 Make no stray marks.
 Do not use pens with ink that soaks through the  Keep all entries within the boxes.
paper.

Please use the scale shown to rate the following aspects of your hearing experience.

Not
Applicable



Very Poor

Good



Poor

Very Good



Fair

Excellent

Mark [X] ONE answer for every item. If a question does not apply to you, please mark Not Applicable.

When you decided to request a hearing…
1.

Ease of finding information about how to file
your hearing request

  




2.

Quality of information you got from Social
Security explaining the hearing process







  









  



While you were waiting for your hearing to be held…
3.

Ease of contacting Social Security about your
hearing request


4.

Helpfulness of the information Social Security
gave you about your hearing request







  

How your hearing was held…
5. Did you have a representative, either an attorney or some other person, handle your hearing?
Mark only ONE answer.

Yes
No
6.

Did you have a hearing with a judge face-to-face or by video conference?
Mark only ONE answer.

Hearing was face-to-face with a judge.
Hearing was by video conference with a judge.
No hearing was held with a judge.

 Please continue with question 7
 Please continue with question 7
 Please continue with question 14

PLEASE CONTINUE TO PAGE 2



Very Good

Good

Poor

Very Poor

Not
Applicable

7.

Location of the office where your hearing was
held







 





8.

How well the judge explained what would
happen at your hearing







 





9.

How prepared the judge was to talk about the
facts of your case







 





10. Opportunity the judge gave you or your
representative to present the facts of your case







 





11. Courtesy of the judge







 





12. Length of time from the date you first
requested your hearing until it was held







 





13. Length of time from the date your hearing was
held until you received the decision







 





14. Overall length of time from the date you first
requested your hearing until you received the
decision







 





Fair

Excellent

Please use the scale shown to rate the following aspects of your hearing experience.
Mark [X] ONE answer for every item

When your hearing was held…

Waiting for the hearing and decision…















Notice of Social Security’s decision on your hearing…
15. How well the notice explained the decision on
your hearing







 





16. How well the notice explained what to do if
you disagreed with the decision







 





17. Helpfulness of the staff







 





18. Courtesy of the staff







 





19. How well the staff knew their jobs







 





20. Overall experience with the hearing on your
disability application







 





21. Overall opinion of Social Security’s service







 





Your overall experience with Social Security…

A little more about you…
22. When you do business with Social Security, in person, on the telephone, or online, do you need them to
provide any special accommodations because of a medical condition?
Mark [X] ONE answer.
 Yes
 No  SKIP to Question 25.
23. Do you need special accommodations because of a:
Mark [X] all that apply.
 Physical limitation (for example, wheelchair access)
 Visual limitation (for example, large print or Braille documents)
 Deafness or difficulty hearing (for example, sign language interpreter or video relay)
 Other limitation (for example, a learning disability)
24. How satisfied are you with how well Social Security meets your need for special accommodations?
Are you:
Mark [X] ONE answer.
 Very satisfied
 Somewhat satisfied
 Somewhat dissatisfied, or
 Very dissatisfied
25. Please use this space to explain any of your answers, especially any reasons for dissatisfaction, or to
provide any other comments about the service you received in connection with your hearing.
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
OMB Control Number 0960-0526, Expiration Date: TBD

FY 2017 Disability Scorecard – Hearing Process Report Card Survey Correspondence
PRENOTICE POSTCARD - ENGLISH

Dear Social Security Applicant:
Social Security believes that conducting surveys is one of the best ways to find out how well we
are serving you. That’s why we will soon be asking you to give us your opinion about the
service you received for your recent business with Social Security.
In a few days, you will receive a short questionnaire in the mail from [Contractor], who is
conducting this survey for Social Security. When you receive their envelope, we hope that you
will take the time to answer our questions and tell us what you think of our service.
We look forward to hearing your opinions.

Social Security Administration

FY 2017 Disability Scorecard – Hearing Process Report Card Survey Correspondence
INITIAL COVER LETTER - ENGLISH

Dear Social Security Applicant:
As noted in our recent postcard, Social Security is conducting a survey to get your opinion of the
service you received when you requested a hearing on your application for Social Security
disability benefits. We would like to hear from you even if you did not attend a hearing with a
judge.
The survey is short and should only take 5 minutes to complete. Please take a few minutes now
to answer the questions and return the form as soon as possible in the postage-paid envelope
provided. While you are not required to respond, your opinions are very important to us and we
would like to hear from as many people as possible. Please do not put any information related
to your Social Security business in the envelope with your completed survey.
Please be assured that [Contractor], who is conducting this survey for us, will only give your
responses to the staff here at Social Security and will not use them for any other purpose. Social
Security will report the survey results by summarizing the answers of everyone who takes the
survey; we will not report any individual responses. Your participation in this survey will not
affect your eligibility for benefits or any business you have with Social Security.
If you have any questions about your hearing request or benefits, please call Social Security’s
toll-free information line at 1-800-772-1213 or visit our web site at www.socialsecurity.gov.
Thank you for sharing your opinions with us.
Sincerely,

Social Security Administration

FY 2017 Disability Scorecard – Hearing Process Report Card Survey Correspondence
FOLLOW-UP POSTCARD - ENGLISH

Dear Social Security Applicant:
About two weeks ago we sent you a survey form asking for your opinion of the service you
received for your recent business with Social Security.




If you have already mailed back your completed survey, thank you for your
quick response.
If not, please take 5 minutes now to complete and return the survey in the
postage-paid envelope provided.
If you no longer have the survey, you don’t need to do anything. [Contractor],
who is conducting the survey for us, will be mailing another form to you shortly.

Thank you for your help with this survey.

Social Security Administration

FY 2017 Disability Scorecard – Hearing Process Report Card Survey Correspondence
FOLLOW-UP COVER LETTER - ENGLISH

Dear Social Security Applicant:
About a month ago we sent you a brief survey asking about the service you received when you
requested a hearing on your application for Social Security disability benefits. We haven’t yet
heard from you and it’s important that we gather opinions from as many people as possible. We
would like you to answer our survey even if you did not attend a hearing with a judge.
If you recently mailed in your completed survey form, please discard this letter. We sincerely
appreciate your help and we look forward to receiving your response. However, if you have not
yet returned the survey, please take 5 minutes now to complete it and send it back. For your
convenience, we have enclosed another copy along with a postage-paid return envelope. Please
do not put any information related to your Social Security business in the envelope with
your completed survey.
Please be assured that [Contractor], who is conducting this survey for us, will only give your
responses to the staff here at Social Security and will not use them for any other purpose. Social
Security will report the survey results by summarizing the answers of everyone who takes the
survey; we will not report any individual responses. Your participation in this survey will not
affect your eligibility for benefits or any business you have with Social Security.
If you have any questions about your hearing request or benefits, please call Social Security’s
toll-free information line at 1-800-772-1213 or visit our web site at www.socialsecurity.gov.
We would appreciate receiving your completed survey as soon as possible.
Sincerely,

Social Security Administration

FY 2017 Disability Scorecard – Hearing Process Report Card Survey Correspondence
PRIVACY ACT - ENGLISH

PRIVACY ACT STATEMENT
The Social Security Administration is authorized to collect the information for this survey under
Executive Order 12862, “Setting Customer Service Standards.” Your response to these
questions is strictly voluntary. The information you provide will be used to help us improve the
service that we give you. Your response will not be disclosed to any other government or private
agency.

PAPERWORK REDUCTION ACT STATEMENT
This information collection meets the requirements of 44 U.S.C. § 3507, as amended by
Section 2 of the Paperwork Reduction Act of 1995. You do not need to answer these questions
unless we display a valid Office of Management and Budget control number. We estimate that it
will take about 5 minutes to read the instructions, gather the facts, and answer the questions. You
may send comments on our time estimate above to: Social Security Administration,
6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time
estimate to this address, not the completed form.

FY 2017 Disability Scorecard – Hearing Process Report Card Survey Correspondence
PRENOTICE POSTCARD - SPANISH

Estimado(a) Solicitante del Seguro Social:
La Administración del Seguro Social cree que una de las mejores maneras de saber si el público está satisfecho
con nuestro servicio es a través de encuestas. Es por eso que muy pronto le estaremos pidiendo su opinión
sobre el servicio que recibió durante su reciente asunto con el Seguro Social.
En unos días, usted recibirá un corto cuestionario por correo de Synovate, quien está llevando a cabo esta
encuesta por parte del Seguro Social. Cuando lo reciba, esperamos que tome el tiempo para contestar nuestras
preguntas y decirnos lo que piensa de nuestro servicio.
Esperamos escuchar sus opiniones.

Administración del Seguro Social

FY 2017 Disability Scorecard – Hearing Process Report Card Survey Correspondence

INITIAL COVER LETTER – SPANISH
Estimado(a) Solicitante del Seguro Social:
Según le indiqué en la tarjeta postal que le envié recientemente, el Seguro Social está llevando a cabo una
encuesta para obtener su opinión sobre el servicio que recibió cuando solicitó una audiencia de su solicitud para
beneficios de Seguro Social por incapacidad. Nos gustaría oír de usted aún si no asistió a una audiencia con un
juez.
La encuesta es corta y le debe tomar sólo 5 minutos en llenarla. Por favor tome unos minutos ahora para
contestar las preguntas y devuelva el formulario lo antes posible en el sobre franqueado provisto. Aunque no
está requerido a responder, sus opiniones son muy importantes para nosotros y nos gustaría oír de tantas
personas como sea posible. Por favor no incluya en el sobre con la encuesta, ninguna información
relacionada a sus asuntos con el Seguro Social.
Por favor, siéntase seguro de que Synovate, quien está llevando a cabo esta encuesta por nosotros, proveerá sus
respuestas solamente a el personal aquí en el Seguro Social y no las usará para ningún otro propósito. El
Seguro Social presentará los resultados de la encuesta con un resumen de las respuestas de todas las personas
que tomen la misma; no presentaremos informes individuales de las respuestas. Su participación en esta
encuesta no afectará su derecho a beneficios o cualquier otro asunto que tenga con el Seguro Social.
Si tiene alguna pregunta sobre su petición para una audiencia o los beneficios, por favor llame al número gratis
del Seguro Social para información al 1-800-772-1213 o visite nuestro sitio de Internet en
www.segurosocial.gov.
Gracias por compartir sus opiniones con nosotros.
Sinceramente,

Administración del Seguro Social

Anexos

FY 2017 Disability Scorecard – Hearing Process Report Card Survey Correspondence

FOLLOW UP POSTCARD – SPANISH

Estimado(a) Solicitante del Seguro Social:
Alrededor de dos semanas atrás, le enviamos una encuesta pidiendo su opinión sobre el servicio que recibió
durante su reciente asunto con el Seguro Social.




Si ya envió la encuesta completada por correo, gracias por su pronta respuesta.
Si no, por favor tome 5 minutos ahora para llenar y devolver la encuesta en el sobre franqueado
provisto.
Si ya no la tiene, no tiene que hacer nada. Synovate, quien está llevando a cabo la encuesta por
nosotros, le enviará otro formulario por correo pronto.

Muchas gracias por su ayuda con esta encuesta.

Administración del Seguro Social

FY 2017 Disability Scorecard – Hearing Process Report Card Survey Correspondence
FOLLOW-UP COVER LETTER – SPANISH

Estimado(a) Solicitante del Seguro Social:
Alrededor de un mes atrás, le enviamos una breve encuesta pidiéndole su opinión sobre el
servicio que recibió cuando solicitó una audiencia de su solicitud para beneficios de Seguro
Social por incapacidad. No hemos oído de usted y es muy importante que reunamos opiniones
de tantas personas como sea posible. Nos gustaría que respondiera a nuestra encuesta aún si no
asistió a una audiencia con un juez.
Si envió la encuesta completada recientemente, favor de ignorar esta carta. Sinceramente
apreciamos su ayuda y estamos ansiosos de recibir su respuesta. Sin embargo, si todavía no la ha
devuelto, por favor tome unos 5 minutos ahora mismo para llenarla y enviárnosla. Para su
conveniencia, hemos incluido otra copia junto con un sobre franqueado. Por favor no incluya
en el sobre con la encuesta, ninguna información relacionada a sus asuntos con el Seguro
Social.
Por favor, siéntase seguro de que Synovate, quien está llevando a cabo esta encuesta por
nosotros, proveerá sus respuestas solamente a el personal aquí en el Seguro Social y no las usará
para ningún otro propósito. El Seguro Social presentará los resultados de la encuesta con un
resumen de las respuestas de todas las personas que tomen la misma; no presentaremos informes
individuales de las respuestas. Su participación en esta encuesta no afectará su derecho a
beneficios o cualquier otro asunto que usted tenga con el Seguro Social.
Si tiene alguna pregunta sobre su petición para una audiencia o los beneficios, por favor llame al
número gratis del Seguro Social para información al 1-800-772-1213 o visite nuestro sitio de
Internet en www.segurosocial.gov.
Le agradeceríamos si recibimos su encuesta llena lo antes posible.
Sinceramente,

Administración del Seguro Social

Anexos

FY 2017 Disability Scorecard – Hearing Process Report Card Survey Correspondence
PRIVACY ACT - SPANISH

DECLARACIÓN DE LA LEY DE CONFIDENCIALIDAD
La Administración del Seguro Social tiene la autorización de colectar la información para esta
encuesta bajo la orden ejecutiva 12862, «Setting Customer Service Standards» (en español,
«Estableciendo el nivel de la calidad del servicio al consumidor»). Sus respuestas a estas
preguntas son completamente voluntarias. La información que nos provea se usará para
ayudarnos a mejorar el servicio que le proveemos. Sus respuestas no serán divulgadas a otras
agencias gubernamentales o privadas.

LEY PARA LA REDUCCIÓN DE TRÁMITES
Esta recopilación de información cumple con los requisitos de 44 U.S.C. &3507, según
enmendada por la sección 2 de La Ley para la Reducción de Trámites del 1995. No es requisito
que usted conteste estas preguntas a menos que el formulario de la encuesta muestre un número
de control válido de la Oficina de Administración y Presupuesto. Calculamos que le tomará
5 minutos para llenar esta encuesta. Esto incluye el tiempo que le tomará leer las instrucciones,
recaudar los datos y contestar las preguntas. Puede enviar comentarios sobre nuestra estimación
del tiempo mencionado anteriormente a: Social Security Administration, 6401 Security Blvd.,
Baltimore, MD 21235-6401. Envíe sólo los comentarios sobre nuestra estimación de tiempo a
esta dirección, no el formulario lleno.