DEEOIC Paper Survey Oxygen and Supplies

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: Paper Survey for Soliciting Feedback for Division of Energy Employees Occupational Illness Compensation (DEEOIC)from claimants who have recently requested authorization for oxygen and/or related supplies (Durable Medical Equipment – DME).

PURPOSE OF COLLECTION: Paper survey designed to gather feedback from claimants who have recently requested authorization for oxygen and/or related supplies (Durable Medical Equipment – DME). DEEOIC has forthcoming operational changes in this area, and this survey will serve as a baseline data collection prior to changes being made, and we plan to conduct another survey after changes have been made. We will use the information to improve our claimant experience and identify potential areas for improvement and/or training. Additionally, we have included questions that are related to equity in order to continue assessing 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 a randomly selected sample of up to 2,000 claimants with requests for oxygen and/or related supplies within the past year.

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 fifteen questions and an optional section where respondents can include their name and phone number for a call back. Ten of fifteen questions include a 1-5 Likert scale response, 2 are yes/no, 1 is multiple choice, and 2 are open response.

5. Please provide your question list.
   
   

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

Survey language attached.

6. When will the activity happen?

DEEOIC will send surveys to the identified claimants during the 3^rd quarter of 2023.

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	333.33
Totals			166.7

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: Allison Spencer

All instruments used to collect information must include:

OMB Control No. 1225-0093

Expiration Date: 02/29/2024

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