ICR A11 Section 280 Clearance - DEEOIC Paper Medical Travel Reimbursement February 2022 - 2-9-2022

Request for Approval under the “Generic Clearance for Improving Customer Experience: OMB Circular A-11, Section 280 Implementation”

(OMB Control Number: 1218-0276)

TITLE OF INFORMATION COLLECTION: Paper Survey for Soliciting Feedback for Division of Energy Employees Occupational Illness Compensation (DEEOIC)

PURPOSE OF COLLECTION: Paper survey designed to gather feedback from claimants under the Energy Employees Occupational Illness Compensation Program Act. Soliciting feedback on what the program does well, if there are any areas for improvement, and an overall idea of how well we serve our stakeholders in this area. We will use the information to improve our claimants’ experiences and identify potential areas for improvement and/or training. Additionally, the survey includes an equity assessment that will provide information on program accessibility and inclusion. We will report the findings of our survey on the Performance.gov website.

TYPE OF ACTIVITY: (Check one)

[ ] Customer Research (Interview, Focus Groups)

[ X ] Customer Feedback Survey

[ ] User Testing

ACTIVITY DETAILS

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ X ] Mail

[ ] Other, Explain

2. Who will you collect the information from?

DEEOIC will collect information from claimants who have recently received medical travel reimbursement from DEEOIC.

3. How will you ask a respondent to provide this information?

DEEOIC will send surveys via U.S. mail and will include a postage-paid return envelope.

4. What will the activity look like?

The mailed package will include a cover letter explaining the purpose of the collection, and a survey with 14 questions and a comment box. Eleven of the questions include a 1-5 Likert scale response, one is a yes/no, one includes check-boxes, and one is open-ended.

5. Please provide your question list.

1.     The process leading up to receiving reimbursement for travel increased my trust in the Division of Energy Employees Occupational Illness Compensation (DEEOIC). 

·        Strongly agree (5)

·        Agree (4)

·        Neutral (3)

·        Disagree (2)

·        Strongly disagree (1)

2.    I am satisfied with the service I have received from DEEOIC thus far.   

·        Strongly agree (5)

·        Agree (4)

·        Neutral (3)

·        Disagree (2)

·        Strongly disagree (1)

3.     The travel reimbursement process moved at a reasonable pace.   

·        Strongly agree (5)

·        Agree (4)

·        Neutral (3)

·        Disagree (2)

·        Strongly disagree (1)

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

·        Strongly agree (5)

·        Agree (4)

·        Neutral (3)

·        Disagree (2)

·        Strongly disagree (1)

5.     My travel reimbursement questions were answered throughout the process. 

·        Strongly agree (5)

·        Agree (4)

·        Neutral (3)

·        Disagree (2)

·        Strongly disagree (1)

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

·        Strongly agree (5)

·        Agree (4)

·        Neutral (3)

·        Disagree (2)

·        Strongly disagree (1)

7.    The employees I interacted with in seeking travel reimbursement were helpful.   

·        Strongly agree (5)

·        Agree (4)

·        Neutral (3)

·        Disagree (2)

·        Strongly disagree (1)

8.    When I disagreed with the amount I was reimbursed for travel, I found it was easy to have it reviewed. 

·        Strongly agree (5)

·        Agree (4)

·        Neutral (3)

·        Disagree (2)

·        Strongly disagree (1)

9.    The amount I was reimbursed for travel was the amount I expected to receive.

·        Yes

·        No

10.   In your interactions with DEEOIC, have you experienced difficulties because of your:

·        Ability or disability status

·  Racial or ethnic identity

·   Age

·   Sex/Gender Identity

·   Veteran Status

·   Religion

·   Social class

·  Geographic location (rural/remote)
·   Other

11.   In my daily life, I have access to affordable transportation.

·        Strongly agree (5)

·        Agree (4)

·        Neutral (3)

·        Disagree (2)

·        Strongly disagree (1)

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

·        Strongly agree (5)

·        Agree (4)

·        Neutral (3)

·        Disagree (2)

·        Strongly disagree (1)

13.   I was treated with respect by DEEOIC representatives.

·        Strongly agree (5)

·        Agree (4)

·        Neutral (3)

·        Disagree (2)

·        Strongly disagree (1)

14.   What do you think DEEOIC could do better to deliver more equitable services? (open-ended response)

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

Script/prompt language attached.

6. When will the activity happen?

DEEOIC will send surveys to claimants during the 2rd quarter of FY 2022.

7. 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	Burden Hours
Claimants	2,000	5 minutes	167
Totals			167

CERTIFICATION:

I certify the following to be true:

1. The collections are voluntary;

2. The collections are low-burden for respondents (based on considerations of total burden hours or burden-hours per respondent) and are low-cost for both the respondents and the Federal Government;

3. The collections are non-controversial and do not raise issues of concern to other Federal agencies;

4. Any 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 near future;

5. Personally identifiable information (PII) is collected only to the extent necessary and is not retained;

6. Information gathered is intended to be used for general service improvement and program management purposes

7. Upon agreement between OMB and the agency aggregated data may be released as part of A-11, Section 280 requirements only on performance.gov. Summaries of customer research and user testing activities may be included in public-facing customer journey maps.

8. Additional release of data will be coordinated with OMB.

Name: Joshua Novack

All instruments used to collect information must include:

OMB Control No. 1218-0276

Expiration Date: xx/xx/xxxx

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