Supplementary Supporting Statement - Web Survey for Soliciting Feedback for Division of Energy Employees Occupational Illness Co

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

(OMB Control Number: 1225-0093)

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

PURPOSE OF COLLECTION: Web survey designed to gather feedback from claimants under the Energy Employees Occupational Illness Compensation Program Act utilizing the Energy Document Portal (EDP) website. Soliciting feedback on how well the tool works, what type of information they use it to submit, if there are any areas for improvement, and an overall idea of how usable the tool is for our stakeholders. We will use the information to improve our claimants’ experiences and identify potential areas for improvement and/or training within EDP. We will report the findings of this on-going 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)
   
   

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

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

2. Who will you collect the information from?

DEEOIC will collect information from claimants and authorized representatives using EDP to submit documentation to DEEOIC.

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

DEEOIC will have a survey option for users right after they submit documentation in the existing EDP system.

4. What will the activity look like?

The web survey will be offered to stakeholders after they have visited the Energy Document Portal to submit documentation to DEEOIC. The survey will identify that it is an optional collection and will include a sentence detailing the purpose of the collection and burden statement information. The survey includes 8 questions, including a comment box. Six of the questions include a 1-5 Likert scale response, one is a multiple choice of document types, and one open-ended comment box.

5. Please provide your question list.

1. What was the primary type of document you uploaded today? (Select one)   

 

• Claims and Forms - All Others 

• Death Records 

• Employment Evidence 

• Fiscal Documents 

• Home Health Care Documents 

• Identification of Authorized Representative 

• Medical Records 

• Objections to Recommended Decision Including Hearing Documents 

• Occupational History Interview 

• Other Documents 

• Phone or Address Change 

• Reconsideration Request 

• Reopening Request 

• Request for Copy of Case File 

• Survivorship Evidence 

• Telephone Records 

• Waivers or Partial Waivers to Recommended Decision 

• Ancillary Medical Services 

 

2. Please rate your experience with EDP today. 

 

• Outstanding (5)   

 

• Above Average (4)   

 

• Average (3)   

 

• Below Average (2)   

 

• Poor (1)   

 

3. I was able to complete the task I set out to do in EDP.  

 

• Strongly agree (5)   

 

• Agree (4)   

 

• Neutral (3)   

 

• Disagree (2)   

 

• Strongly disagree (1)   

 

4. It was easy to complete my document upload in EDP. 

 

• Strongly agree (5)   

 

• Agree (4)   

 

• Neutral (3)   

 

• Disagree (2)   

 

• Strongly disagree (1)   

 

5. It was easy to complete my document upload in EDP. 

 

• Strongly agree (5)   

 

• Agree (4)   

 

• Neutral (3)   

 

• Disagree (2)   

 

• Strongly disagree (1)   

 

6. I understood what was being asked of me throughout the process. 

 

• Strongly agree (5)   

 

• Agree (4)   

 

• Neutral (3)   

 

• Disagree (2)   

 

• Strongly disagree (1)   

 

7. This interaction increased my trust in DEEOIC.  

 

• Strongly agree (5)   

 

• Agree (4)   

 

• Neutral (3)   

 

• Disagree (2)   

 

• Strongly disagree (1)   

 

8. Do you have any additional feedback on EDP?  

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 work to establish the survey within EDP in late Q3 of FY22. This survey will be ongoing.

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	7,000	3 minutes	350
Totals			350

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. 1225-0093

Expiration Date: 06/30/2024

8