Voluntary Demographic Information

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: Voluntary Demographic Information

PURPOSE OF COLLECTION: OWCP Longshore Leadership will continue to collect demographic data for new account creation, using the revised instrument. Existing accounts will have their previous demographic survey data wiped, with the opportunity to provide responses to the new instrument data. The purpose also includes the ability to join demographic data in profile with survey responses via a unique ID.

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?

The information obtained will be collected from participants of the ECOMP user software who voluntarily chooses to answer survey questions. ECOMP is a customer portal that allows authorized/registered parties to view their case data throughout the claims process with the OWCP Longshore program. The survey information requested will appear following the user’s selection to complete a section titled Voluntary Demographic Information.

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

The survey will appear following the Voluntary Demographic Information section via a survey pop-up window.

4. What will the activity look like?

The activity will involve a standard survey where a pop-up window will be the actionable portion to complete. Participants voluntarily will complete this.

5. Please provide your question list.

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

Text at Start of Collection

Voluntary Demographic Information

Public Burden Statement

Thank you for agreeing to take our survey. Your feedback will allow us to improve our system and better serve our claimants. The OMB control number for this collection is 1225-0093 and expires on February 29, 2024. According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number. The public reporting burden for this collection of information is estimated to average 5 minutes to complete, including time for reviewing instructions, searching existing data sources, gathering the data needed, and completing and reviewing the collection of information. The obligation to respond to this collection is voluntary (5 U.S.C. § 8101 et seq.) to obtain or retain a benefit. You are not required to respond to this collection of information unless it displays a valid OMB control number. Please send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Office of Workers' Compensation Programs, U.S. Department of Labor, Room S3229, 200 Constitution Avenue, N.W. Washington, D.C. 20210, and reference the OMB Control Number 1225-0093.

The collection of this information is voluntary. It is not required, and it will not be available to or used by OWCP staff during the claims process. This voluntary data is anonymous, confidential, and will only be accessed without personal identifiable information by non-claims staff.

The information is being collected to help us improve customer service. Additionally, this data may be able to assist us so that we can develop more effective outreach strategies and improve access to program services and benefits, especially to underserved communities.

You may answer all, some, or none of the questions below. [If you do not wish to participate, please click NEXT and you will continue to the final step in the account creation process.]

Thank you in advance for your assistance.

Voluntary Demographic Questions

Race/Ethnicity

Are you Hispanic or Latino?

• Yes, Hispanic or Latino.

• No, not Hispanic or Latino.

What is your race? (Select all that apply. Note, you may report more than one group.)

• White

• Black or African American

• Asian

• American Indian or Alaska Native

• Native Hawaiian or Pacific Islander

Sexual Orientation

Which of the following best represents how you think of yourself?

• Gay or lesbian

• Straight, that is not gay or lesbian

• Bisexual

• I use a different term {free text}

• I don’t know

Gender Identity

What sex were you assigned at birth, on your original birth certificate?

• Female

• Male

How do you currently describe yourself (mark all that apply)?

• Woman

• Man

• Transgender

• I use a different term {free text}

Just to confirm, you were assigned {auto-FILL} at birth and now you describe yourself as {auto-FILL}. Is that correct?

• Yes

• No <skip back to Q1 and/or Q2 to correct>

Primary Language

How well do you speak English?

• Very well

• Well

• Not well

• Not at all

Do you speak a language other than English at home?  

• Yes

• No 

If you answered “Yes” to question 2, please answer question 3, below:

What is this language? (Check all that apply)

• Spanish

• Chinese

• French (Including Patois, Cajun, Creole, Haitian)

• Tagalog

• Vietnamese

• Arabic

• Korean

• Russian

• German

• Hindi

• Portuguese

• Other Language Not Listed: _________________

Disability Status

Are you deaf or do you have serious difficulty hearing?

• Yes

• No

Are you blind or do you have serious difficulty seeing, even when wearing glasses?

• Yes

• No

Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?

• Yes

• No

Do you have serious difficulty walking or climbing stairs?

• Yes

• No

Do you have difficulty dressing or bathing?

• Yes

• No

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?

• Yes

• No

6. When will the activity happen?

This survey is currently scheduled to remain on the website at this time following approval to continually gather pertinent demographic data critical to the mission needs of the program.

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
Registered Entities	145	5 minutes	12
Registered Claimants	3,011	5 minutes	251
Totals	3,156	10 minutes	263

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:

Joseph Harris

All instruments used to collect information must include:

OMB Control No. 1225-0093

Expiration Date: 02/29/2024

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