Work Incentive Planning and Assistance (WIPA) Customer Comment Instrument

Of fice of Management and Budget Control Number

Work Incentive Planning and Assistance (WIPA) Services feedback questionnaire

Date completed:

QUALITY OF WIPA STAFF AND SERVICES
Please indicate how satisfied you were with services provided by the WIPA staff. Not Applicable (NA) Very dissatisfied (1) Somewhat dissatisfied (2) Neither satisfied nor dissatisfied (3) Somewhat satisfied (4) Very satisfied (5)
WIPA staff…	NA	1	2	3	4	5
Conducted meetings and returned my phone calls or emails in a timely manner.
Treated me with respect and confidentiality.
Provided high quality, valid and reliable information.
Showed me specifically how my benefits would be affected by working.
Helped me understand how other programs and benefits I receive would be impacted by working.
Told me what situations might occur and when I should contact them in the future
Contacted me again after a certain point of time to check my employment status and further services with me.

QUALITY OF WIPA OUTCOMES
Please indicate how satisfied you were with services provided by the WIPA staff. Not Applicable (NA) Very dissatisfied (1) Somewhat dissatisfied (2) Neither satisfied nor dissatisfied (3) Somewhat satisfied (4) Very satisfied (5)
WIPA staff…	NA	1	2	3	4	5
Referred me to services that helped me identify and/or select my career goal.
Helped me resolve a benefit related issue (i.e., overpayment, approval of work incentives, etc.)
Provided me with information about who to contact, notify and/or keep up to date when I start working
Overall, I am satisfied with the information and help provided by the WIPA staff.

“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 3 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.”

Thank you for completing this feedback questionnaire. We look forward to working with you in the future.

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