User feedback for the Benefit Cliff Calculator

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Form Approved
   OMB No. 0990-0379
   Exp. Date 09/30/2023
QUESTIONS FOR MTRC POP-UP SURVEY 
These questions would appear in a pop-up survey after someone uses the tool. The text that is in blue is what the calculator user would see. 
Screen 1: 
Thank you for using the <name TBD> calculator. Please take 3-4 minutes to give us your feedback to improve this calculator! 
Please choose one: <Question one creates a branch, sending caseworkers and benefits recipients down separate arms of the survey. Respondents will EITHER complete branch A OR B, not both.> 
        A. I receive benefits 			B. I am a caseworker
↓					↓
Screen 2/Benefits Recipients (BR)
How easy or difficult was it to use the calculator? <slider allows user to move on a continuum between “Very Hard” and “Very Easy”>

Screen 2/Caseworkers (CW)
How easy or difficult was it to use the calculator? <slider allows user to move on a continuum between “Very Hard” and “Very Easy”>

Screen 3/BR
How useful are the results that the calculator provided? (Did you learn anything that could help you plan your household income?)<slider allows user to move on a continuum between “Very Useful” and “Not Useful At All”>
Screen 3/CW
How useful are the results that the calculator provided? <slider allows user to move on a continuum between “Very Useful” and “Not Useful At All”>
Screen 4: BR
What is your next step? <select all that apply>
        ◦ Meeting with my caseworker
        ◦ Find out how I can change my earnings (e.g., support for education, job training, skill building)
        ◦ Change my earnings, if possible
        ◦ Visit a <branded name for local job center>
        ◦ No need for any next steps at this time
        ◦ I’m not sure
Screen 4a: CW
What is your next step? <select all that apply>
        ◦ Meeting with my client
        ◦ Encouraging my client to change their earnings, if possible
        ◦ Suggesting my client visit <branded name for local job center>
        ◦ No need for any next steps at this time
        ◦ I’m not sure

Screen 4b: If CW selected the second bullet in 4a, they will see this screen 
I am encouraging my client to pursue: <select all that apply> 
        ◦ Educational support
        ◦ Workforce/Workforce Innovation and Opportunity (WIOA) Programs 
        ◦ Other support programs (please specify) <box for open-ended response>
Screen 5: BR
How could we make this tool better? <open ended response> there would be a large “DONE” button at the end. 
Screen 5: CW 
How could we make this tool better? <open ended response> there would be a large “DONE” button at the end.
Screen 6: BR 
Thank you!
Screen 6: CW 
Thank you!


According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990-0379. The time required to complete this information collection is estimated to average 3-4 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:  U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201,   Attention: PRA Reports Clearance Officer