Requests for Alternative Formats for Blind and Visually Impaired Individuals Communicating with SSA
Exit this survey
1. Default Section
1
. Do you receive benefits from SSA?
Do you receive benefits from SSA?
As a beneficiary (SSDI, Retirement, etc.)
As a recipient (SSI)
As a representative payee
I don't yet, but I'm applying for benefits
My benefits have been reduced, suspended or terminated, and I disagree with SSA about this
2
. If your SSA benefits have been suspended, reduced or terminated, what reason did SSA provide?
If your SSA benefits have been suspended, reduced or terminated, what reason did SSA provide?
No longer eligible due to earnings
Overpayment
Failure to respond to notice or comply with program rules
No longer disabled
Don't know because I can't read standard print
3
. Did you get a notice on or around January 1, 2010 from SSA describing the court case, American Council of the Blind v. Astrue, and recognizing your right under federal law (Section 504 of the Rehabilitation Act) to ask for notices and other information about your benefits from SSA in an alternate format in addition to standard print?
Did you get a notice on or around January 1, 2010 from SSA describing the court case, American Council of the Blind v. Astrue, and recognizing your right under federal law (Section 504 of the Rehabilitation Act) to ask for notices and other information about your benefits from SSA in an alternate format in addition to standard print?
Yes
No
4
. If you had asked for telephone calls in the past, did SSA contact you by telephone to read the notice informing you of your right to receive alternative formats prior to February 2, 2010?
If you had asked for telephone calls in the past, did SSA contact you by telephone to read the notice informing you of your right to receive alternative formats prior to February 2, 2010?
Yes, and I understood the notice
Yes, but the SSA representative who called me did not read the entire notice to me
Yes, but I could not understand the SSA representative who called me
No, SSA has not called yet and I've requested phone calls
N/a because I haven't ever requested phone calls
5
. If you have made a request either to receive your notices and communications from SSA in Braille or Microsoft Word on CD, please indicate:
If you have made a request either to receive your notices and communications from SSA in Braille or Microsoft Word on CD, please indicate:
How you made your request (by phone, in person, etc.)?
When did you make your request?
Did you have any difficulties making your request, if so please explain.
6
. Have you made a request to receive another format such as large print, audio cassette, or audio CD?
Have you made a request to receive another format such as large print, audio cassette, or audio CD?
When did you make your request?
How did you make your request?
If you had difficulties making your request, please explain.
7
. If you recall whom you spoke to at SSA and where the SSA representative was based, please provide that information below:
If you recall whom you spoke to at SSA and where the SSA representative was based, please provide that information below:
Name (first and last if available) of SSA agent you contacted:
Please indicate whether the representative was at a teleservice office or a field office and where the representative was located (this is important for us to monitor problems, if they occur):
8
. If you are currently receiving an alternative format of your choice, then:
If you are currently receiving an alternative format of your choice, then:
What is it?
When did you start receiving it?
Are you satisfied with how SSA provides notices to you?
If not, please explain.
9
. Please provide comments, questions, or concerns below.
Please provide comments, questions, or concerns below.
*
10
. Please provide your contact information so that we can follow-up. If you do not have an address or phone number please provide an alternate contact (friend, family, etc.) if possible:
Please provide your contact information so that we can follow-up. If you do not have an address or phone number please provide an alternate contact (friend, family, etc.) if possible:
First and Last Name
Address
Phone number
E-mail
Powered by
SurveyMonkey
Check out our
sample surveys
and create your own now!
Javascript is required for this site to function, please enable.