Category D Comment Card Questionnaire Sample

OUR COMMITMENT TO YOU

When you conduct business with us:

• We will provide service through knowledgeable employees who will treat you with courtesy, dignity and respect every time you do business with us.
  
  

• We will provide you with our best estimate of the time needed to complete your request and fully explain any delays.
  
  

• We will clearly explain our decisions so you can understand why and how we made them and what to do if you disagree.
  
  

PRIVACY ACT

The Social Security Administration is authorized to collect the information on this comment card under Section 702 of Title VII of the Social Security Act. 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.

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 control number. We estimate that it will take you about 5 minutes to read instructions, gather the facts, and answer the questions. SEND OR BRING THE COMPLETED FORM TO YOUR LOCAL SOCIAL SECURITY OFFICE. The office is listed under U.S. Government agencies in your telephone directory or you may call Social Security at 1-800-772-1213 (TTY 1-800-325-0778). 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.

PLEASE FILL OUT AND MAIL

Social Security Administration Form Approved OMB No. 0960-0526
HOW DID YOU LIKE OUR VIDEO SERVICE?
DATE		LOCATION (City/State):
DID YOU VISIT TO:
 Report a Change for Your Records  Apply for disability benefits  Request a benefit verification  File an appeal		 Apply for retirement or survivors benefits  Apply for SSI benefits  Apply for a Social Security Card  Other (specify) _________________
Did you have an appointment?  Yes  No		How long did you wait to be served?  30 minutes or less  More than 30 minutes
Blacken the circle which corresponds closest to your feelings.
HOW SATISFIED WERE YOU WITH:
	Very Satisfied					Very Dissatisfied
The overall service you received							
Convenience of using video service							
The ease of using video service							
The clarity of the communication							
The privacy of the video site							
If you used the Video Service at a site other than a Social Security office, did you like the location of the site? Yes/ No If no, why not: ___________________________________________________________________________ ___________________________________________________________________________ COMMENTS/SUGGESTIONS TO IMPROVE OUR VIDEO SERVICE
Name (Optional)		Telephone Number (Optional) (Area Code)
Address (Optional)

Approved, OMB Number 0960-0526

To the Public We Serve:

The Social Security Administration is committed to high-quality service. Providing high-quality service is more than just a slogan to us. It is our commitment to find out what you want and then continually improve the ways we deliver service to meet your expectations.

You can help us to improve our video service by taking a few minutes to answer the questions on this customer comment card. Please answer these questions based on your own experience with Social Security.

Don't delay; your responses are very important. Please mail the completed postage-paid comment

card to us.

Thank you for your assistance.

Best regards,

Linda S. McMahon

Deputy Commissioner

Office of Operations