Medical Travel Survey

U.S. Department of Labor

Office of Workers’ Compensation Programs
Division of Energy Employees Occupational Illness Compensation
200 Constitution Ave, NW, Room C-3321
Washington, D.C. 20210

Dear Claimant, 
Our  records  indicate  that  you received  medical  travel  reimbursement  from  Division  of  Energy 
Employees Occupational Illness Compensation (DEEOIC). We are very interested in receiving feedback 
on your experience with DEEOIC.  
Your participation in the enclosed Customer Experience and Equity Surveys will help us improve the 
claimant/customer experience. 
We appreciate your assistance in helping us determine what is working and what may be improved. 
The following survey is confidential. Please return this survey using the enclosed postage paid 
envelope by MONTH DATE YEAR. 
Thank you for your participation. 
Stakeholder Engagement 
Branch of Outreach and Technical Assistance
Division of Energy Employees Occupational Illness Compensation 

OMB Control Number: 1218-0276
Expiration Date: 2/29/2024

U.S. Department of Labor

Office of Workers’ Compensation Programs
Division of Energy Employees Occupational Illness Compensation
200 Constitution Ave, NW, Room C-3321
Washington, D.C. 20210

CUSTOMER EXPERIENCE SURVEY
Please agree or disagree with the following statements
bycircling a response:
The process leading up to receiving reimbursement for travel increased my
trust in the Division of Energy Employees Occupational Illness Compensation
(DEEOIC).
I am satisfied with the service I have received from DEEOIC thus far.

Strongly
Strongly
Agree Neutral Disagree
N/A
Agree
Disagree

5

4

3

2

1

n/a

5

4

3

2

1

n/a

The travel reimbursement process moved at a reasonable pace.

5

4

3

2

1

n/a

I understood what I needed to provide for approval for travel reimbursement.

5

4

3

2

1

n/a

My travel reimbursement questions were answered throughout the process.

5

4

3

2

1

n/a

The Travel Reimbursement Form (OWCP-957) was self-explanatory and
easy to complete.

5

4

3

2

1

n/a

5

4

3

2

1

n/a

5

4

3

2

1

n/a

Yes

No

The employees I interacted with in seeking travel reimbursement were helpful.
When I disagreed with the amount I was reimbursed for travel, I found it was
easy to have it reviewed.
The amount I was reimbursed for travel was the amount I expected to receive.

n/a

Additional Comments:

Over

OMB Control Number: 1218-0276
Expiration Date: xx/xx/xxxx

U.S. Department of Labor

Office of Workers’ Compensation Programs
Division of Energy Employees Occupational Illness Compensation
200 Constitution Ave, NW, Room C-3321
Washington, D.C. 20210

EQUITY ASSESSMENT
OWCP / DEEOIC is committed to finding ways to focus on equity for all, including people who have been historically
marginalized or adversely affected by inequality. We strive for fair, just, and impartial treatment of all, including racial
and ethnic minorities, persons with disabilities, the LGBTQ+ community, rural communities, and other underserved
populations. We want to improve program accessibility and inclusion.
In your interactions with DEEOIC,
have you experienced difficulties
because of your:
Ability or disability status



Racial or ethnic identity



Age



Sex/Gender identity



Sexual orientation



Veteran status



Religion



Social class



Geographic location
(rural/remote)



Other________________



Please agree or disagree with
the following statements by
circling a numerical response:

Strongly
Agree

Agree

Neutral

Disagree

Strongly
Disagree

N/A

I feel comfortable talking with
DEEOIC representatives about
the unique issues I face.

5

4

3

2

1

n/a

I was treated with respect by
DEEOIC representatives.

5

4

3

2

1

n/a

What do you think DEEOIC could do better to deliver more equitable services?

The OMB control number for this collection is 1218-0276 and expires on 02/29/2024. According to the Paperwork Reduction Act of 1995, no person is required to respond to a collection of
information unless such collection displays a valid OMB control number. The obligation to respond to this collection is voluntary. We estimate it takes about 5 minutes to complete this collection of information, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing the collection of information. Please
send comments regarding the burden estimate or any other aspect of this collection of information to the U.S. Department of Labor, DEEOIC, 200 Constitution A ve., NW , Room C-3321,
Washington, D.C. 20210 and reference OMB Control Number 1218-0276.
Note: Please do not return the completed form to this address.
OMB Control Number: 1218-0276
Expiration Date: xx/xx/xxxx