National Disability Forum (NDF)

Live Stream or In Person Example

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. Please note that questions marked with an asterisk require a response.

Demographics

*1. Your organization type:

• Federal Government – Social Security Administration (SSA) only

• Federal Government – Others

• State Government – Disability Determination Services (DDS) / Disability Adjudication Services (DAS) only

• State Government – Others

• Local Government

• Private

• Nonprofit

• College/University

• Healthcare

• Faith-based

• Military

• Other (please specify)

*2. How did you learn about the forum?

• Email from SSA

• Socialsecurity.gov

• National Disability Forum Website

• Social Security Update Newsletter

• Facebook

• Google Plus

• LinkedIn

• Twitter

• Blogs or Community Chats

• Internet Search

• Colleague

• Other (please specify)

*3. Did you attend the forum by livestream or in-person?

• Livestream

• In-person

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

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

8. Which topics would you like to see covered at future forums?

Topic 1 ____________________________________

Topic 2 ____________________________________

Topic 3 ____________________________________

Communication Resources

*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 (please specify)

Contact Information

10. Your contact information (optional)

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.

Last updated: September 18, 2018