Longshore ECOMP-Instrument (1st Survey)

Voluntary Demographic Information (Be Counted or Be Invisible)

OMB Control Number: 1225-0093

Expiration Date: 02/29/2024

THIS SURVEY OPTION WILL APPEAR AT THE END OF THE ECOMP REGISTRATION PROCESS.

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 person is required to respond to a collection of information unless such collection displays a valid OMB control number. Collection of this information is authorized by OMB. The obligation to respond to this collection is voluntary. We estimate it takes about 5 minutes to complete.

On January 20, 2021, President Biden issued an Executive Order, Advancing Racial Equity and Support for Underserved Communities Through the Federal Government. Consistent with this Executive Order and to advance equity across the Federal Government, we are seeking demographic data for the population of claimants served by the Office of Workers’ Compensation (OWCP). 

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 adjudication process.

The information is being collected to help us address any systemic barriers in accessing benefits available from OWCP, and so that we can develop effective outreach strategies to ensure unfettered 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 SKIP DEMOGRAPHICS and you will continue to the final step in the account creation process.

Thank you in advance for your assistance.

If they click “Skip Demographics” – message says “Thank you for your consideration.”

If they click “Take Survey” – they get this:

SURVEY POP UP

Please specify your race (may check more than one).

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or Other Pacific Islander

• White

• Prefer Not to Say

• Other _____

Please specify your ethnicity.

• Hispanic or Latino

• Not Hispanic or Latino

• Prefer Not to Say

• Other _____

What is the primary language spoken in your household?

• English

• Spanish

• Prefer Not to Say

• Other _____

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

• Male

• Female

• Prefer Not to Say

How do you describe yourself?

• Male

• Female

• Transgender

• Non-Binary

• Do not identify as Female, Male, Non-Binary or Transgender

• Prefer Not to Say

Please specify your sexual orientation.

• Gay or lesbian

• Straight, that is not gay or lesbian

• Bisexual

• Prefer Not to Say

• Other _____

Please specify your marital status.

• Never married

• Married (same sex)

• Married (not same sex)

• Domestic partnership (same sex)

• Domestic partnership (not same sex)

• Divorced

• Widowed

• Prefer Not to Say

• Other _____

Please specify your religion.

• Christianity/Catholicism

• Islam

• Judaism

• Buddhism

• Hinduism

• N/A

• Prefer not to say

• Other ____

Please choose one of the following options related to disability status.

• Yes, I have a disability or have a history/record of having a disability

• No, I don’t have a disability or a history/record of having a disability

• Prefer not to say

Please choose one of the following options related to veteran status.

• I am a veteran (I served in the US Armed Forces)

• I am not a veteran (I did not serve in the US Armed Forces)

• Prefer not to say

Do you have access to affordable transportation?

• Yes

• No