Survey Template - Vision 2025 Customer Expectation Survey

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

TITLE OF INFORMATION COLLECTION: Vision 2025 Customer Expectation Survey

PURPOSE: The Social Security Administration (SSA) is currently developing a long-range vision (Vision 2025) to ensure we continue to provide excellent service to our customers today, tomorrow, and 10 years in the future. One aspect of developing the vision is external outreach and engagement with stakeholders. The purpose of this survey is to engage the public and solicit feedback regarding expectations and preference in conducting business with SSA.

DESCRIPTION OF RESPONDENTS:

Our SSA-approved contractor will be soliciting feedback from the general public via an electronic survey tool (an online survey hosted by Survey Monkey). In addition, SSA public affairs specialists and field office managers will also enlist public participation during SSA informational promotional events with the public (e.g. local community events on health and wellness, retirement, disability awareness, income security, etc.). At these events, SSA representatives will facilitate survey participant response to the online survey via laptop computers.

TYPE OF COLLECTION: (Check one)

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

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

[] Focus Group [X] Other: Online survey

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: , SSA

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

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 N/A

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)
Survey participants – Public	4800	5	400
Totals	4800	5	400

FEDERAL COST: The estimated annual cost to the Federal Government is $300.

Cost includes a one year subscription to Survey Monkey Tool for conducting the survey electronically.

If you are conducting a focus group or survey, 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)

[X ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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

3. Please make sure that all instruments, instructions, and scripts are submitted with the request.

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