CX Survey - Denied Claim

OMB Control Number: 1225-0093 OMB Expiration Date: 2/29/2024 U.S. DEPARTMENT OF LABOR

Office of Workers' Compensation Programs Division of Coal Mine Workers’ Compensation

Paperwork Reduction Act Statement

A Federal agency may not conduct or sponsor an information collection subject to the requirements of the Paperwork Reduction Act unless the information collection has a currently valid OMB Control Number. The approved OMB Control Number for this information collection is 1225-0093 (expires 2/29/2024). Without this approval, we could not conduct this survey. Public reporting for this information collection is estimated to be approximately 5 minutes per response. All responses to this information collection are voluntary. Send comments regarding this burden estimate or any other aspect of this information collection, including suggestions for reducing this burden to U. S Department of Labor, DCMWC, 200 Constitution Ave., N. W., Suite C-3520, Washington, DC 20210 or email at [email protected].

CUSTOMER EXPERIENCE SURVEY

Please circle a numerical response for each of the following questions:	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree	N/A
I trust the Federal Black Lung Program to fulfill our country’s commitment to mine workers and survivors. Additional Comments:	5	4	3	2	1	n/a
Except for the outcome of my decision, I was satisfied with the service I received from the Federal Black Lung Program. Additional Comments:	5	4	3	2	1	n/a
It took a reasonable amount of time for my decision to be issued. Additional Comments:	5	4	3	2	1	n/a
The correspondence or letters I received from the Federal Black Lung program were clear and understandable. Additional Comments:	5	4	3	2	1	n/a
The Black Lung Representatives that I interacted with were helpful. Additional Comments:	5	4	3	2	1	n/a

1. Have you ever attempted to use the Federal Black Lung Program’s Claimant Online Access Link (C.O.A.L.) portal to submit case documents electronically?

 Yes [Go to next question]

 No [Skip to Question 3]

2. How was your experience using the C.O.A.L. portal? Select the response that best matches your experience.

I was able to upload my documents easily.

I was able to upload my documents with difficulty.

I was not able to upload my documents.

3. Why have you never attempted to use the C.O.A.L. portal? Select the response that best matches your experience.

I was not aware it existed.

I found it too confusing/intimidating to even try.

 I generally prefer paper to online.

 Other ______________

Do you have internet access?  Yes  No

The C.O.A.L. Mine Portal can be found at- https://eclaimant.dol.gov/portal/?program_name=BL

BARRIERS TO ACCESS SURVEY

The OWCP/Federal Black Lung Program is committed to finding ways to remove barriers, advance equity for all, and improve program accessibility and inclusion. Your responses to the questions below will help us improve inclusion and accessibility for the Federal Black Lung program:

In your interactions with the Federal Black Lung Program, have you experienced difficulties during the application process?  YES  NO

Difficulties may include policies, practices, procedures, conditions, or obstacles that limit or prevent equitable access to the Federal Black Lung Program.

If yes, please identify where you encountered difficulties. Check all that apply:

 Form Completion  Physician Selection  Physician Scheduling  Physician Examination

 Requested Information  Travel Reimbursement  Other: _____________

Please explain how the above contributed to difficulties in the application process:

Would you like to speak with a Federal Black Lung Program Representative?  YES  NO

If yes, please provide your name and telephone number: Name: _______________________ Phone: ___­­­­­­­­­­­­­­­­­­­­­______________

Additional Comments:

VOLUNTARY DEMOGRAPHIC INFORMATION

We are collecting demographic data to help us address any systemic barriers in accessing benefits available under the Black Lung Benefits Act. The collection of this information, and all other information on this survey, is voluntary. You do not have to answer, and this information will not be available to, or used, by Office of Workers’ Compensation Programs staff in the consideration of your claim. You may answer all, some, or none of the questions on this survey, including the questions below.

What is your Race or Ethnicity: (Select all that apply)  White  Hispanic or Latino  Black or African American  Asian  American Indian or Alaska Native  Middle Eastern or North African  Native Hawaiian or Other Pacific Islander Sexual Orientation:  Gay or lesbian  Straight, that is not gay or lesbian  Bisexual  I use a different term___________  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 different term ____________	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 yes, what is this language? (Select all that apply)  Spanish  French (including Patois, Cajun, Creole, Haitian)  Chinese  Tagalog  Vietnamese  Arabic  Korean  Russian  German  Hindi  Portuguese  Other Language Not Listed: _______________
Do you identify as having a disability other than Black Lung?  Yes  No If yes, please describe your disability.