National Disability Forum (NDF)

National Disability Forum Evaluation

Acquisition and Usage of Electronic Medical Records

OMB Number 0960-_0788 ___

Thank you for taking the time to participate in this evaluation. Your comments will enable us to improve future forums and tailor them to meet your expectations.

Demographics

1. Your organization type:

• Federal Government - SSA only

• Federal Government - Military only

• Federal Government - All Others

• State Government

• Local Government

• Business

• Nonprofit

• College/University

• Health care

• Faith-based

• Military

• Other (please specify) ___________________

2. How did you learn about the forum?

• Email from SSA

• Colleague

• Socialscurity.gov

• Social media

• Other (please specify)_________________________________

3. Did you attend the forum by live streaming or in person?

• Live Streaming

• Person

4. On a scale of 1 to 5, with 5 being the best score and 1 being the worst score, how would you rate the following aspects of the forum?

	1	2	3	4	5
Forum Overall
Content
Format/Structure
Length
Location
Opportunity for audience participation
Usefulness of the topic
Discussions
Live Streaming
Presenters

Other (please specify) _______________________________________ _______________________________________

5. If you rated any of the items in Question 4 above as "1" or "2," please explain why.

___________________________________________________________________________________________________________________________________________________________________________

6. What did you like best about the forum?

___________________________________________________________________________________________________________________________________________________________________________

7. What did you like least about the forum?

____________________________________________________________________________________________________________________________________________________________________________

Future Forums

National Disability Forum Evaluation

8. What recommendations do you have for future Disability Forums?

Topic 1___________________________________________________

Topic 2___________________________________________________

Topic 3___________________________________________________

Communication Resources

National Disability Forum Evaluation

9. How do you typically review news and information about SSA? (Select all that apply)

• SSA website

• SSA emails

• Social media

• Newspapers

• Congressional testimony

• "Social Security Matters" blog

• Other (specify)_______________________________________

Contact Information

National Disability Forum Evaluation

10. Your contact information (optional)

and the Modern Day Workforce

Name___________________________________________________

Email address_____________________________________________

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 (OR participate in this focus group OR

complete this telephone survey) unless we display a valid Office of Management and Budget control number. We estimate that it will

take about 2 minutes to read the instructions, gather the facts, and answer the questions. You may send comments on our time

estimate above to: SSA, 6401 Security Blvd., Baltimore, MD 21235-6401. Send only comments relating to our time estimate to this

address, not the completed form.