Category C Sample

OMB Control No. 0960-0526

Expiration Date: August 2012

In-person Work Incentives Seminar Event (WISE) Evaluation for Employment Networks

Thank you for attending today’s WISE; we hope you found the information helpful! Please let us know how we can improve WISE so we can offer the best possible support to people with disabilities go to work.

Please choose the answer or number that best describes your WISE experience.

1. How did you hear about today’s WISE presentation? (Check all that apply)

WIPA	E-mail	Facebook
Listserv	Twitter	Flyer
Friend/Family	Colleague	Protection and Advocacy Agency
MAXIMUS
Website (Please specify) ________________________________________________________________________
Other (Please specify) _________________________________________________________________________

2. I have attended a WISE before:

• Yes

• No

If yes, how many? Please fill in the blank: _________________________

For each of the following questions, please indicate how much you agree or disagree with the following statements.

1 = Strongly Disagree 5 = Strongly Agree

3. Today’s WISE was a valuable experience 1 2 3 4 5 N/A

4. Today’s WISE allowed me to meet prospective clients 1 2 3 4 5 N/A

5. The question and answer session was helpful 1 2 3 4 5 N/A

6. I plan to attend another WISE 1 2 3 4 5 N/A

7. Today’s WISE location was easy to find 1 2 3 4 5 N/A

8. My request(s) for assistive aids and services was met 1 2 3 4 5 N/A

9. How did you register for WISE?

• Online

• By phone

• By email

• Other (Please Specify) ______________________________________________________

• N/A

10. How would you rate your registration experience?

1=Poor 5 = Excellent

• Online 1 2 3 4 5 N/A

• By phone 1 2 3 4 5 N/A

• By email 1 2 3 4 5 N/A

What suggestions do you have for improving the WISE presentation?

_________________________________________________________________________________________

Paperwork Reduction Act Statement

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 complete this survey. You may send comments on our time estimate above: SSA, 6401 Security Blvd., Baltimore, MD  21235-6401. Send only comments relating to our time estimate to this address.