Template Description Field Office Customer Comment Card

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0960-0788)

TITLE OF INFORMATION COLLECTION:
Field Office (FO) Customer Comment Card (Form SSA-117-PC)

PURPOSE:
The purpose of the comment card is to collect feedback from SSA field office visitors based on their own personal experience while visiting the office. The comment card allows visitors the opportunity to provide feedback on the following:

• Reason for visit (Social Security card, disability benefits, retirement/survivors benefits, Medicare, etc);

• How satisfied they were with the service provided by field office staff;

• Comments and suggestions on how the field office can improve their service.

Completion of the comment card is voluntary. The information from the comment cards allows our offices to see where their strengths and weaknesses lie when providing service to the public. It also helps offices quickly meet the expectations of customers.

DESCRIPTION OF RESPONDENTS:

Public visiting SSA field offices for numerous services such as filing:

• Retirement Benefits

• Disability Benefits

• Survivors Benefits

• Social Security Card

TYPE OF COLLECTION: (Check one)

[X] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[] Focus Group [ ] Other: ______________________

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

2. The collection is low-burden for respondents and low-cost for the Federal Government.

3. The collection is non-controversial and does not raise issues of concern to other federal agencies.

4. The results are not intended to be disseminated to the public.

5. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

6. The collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the future.

Name: Faye Lipsky, Reports Clearance Officer, Social Security Administration

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [X] No

2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ ] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [X] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time (minutes)	Burden (hours)
Field Office Visitors	72,780	5	6,065
Total	72,780		6,065

FEDERAL COST: The estimated annual cost to the Federal government is $3,033.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents

1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe? [ ] Yes [X] No

If the answer is yes, please provide a description of both below (or attach the sampling plan)? If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

Administration of the Instrument

1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[X] Mail

[X] Other, Explain

We will collect the information via mail or in office.

2. Will interviewers or facilitators be used? [ ] Yes [X ] No

How will we conduct the survey?

We have the comment card placed in SSA field offices readily available in reception areas. Office visitors can obtain and complete the comment card either in the office or at home. Completion of the comment card is voluntary.

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