Oxygen and Accessories DME Survey

U.S. Department of Labor

Office of Workers’ Compensation Programs
Division of Energy Employees Occupational
Illness Compensation
Washington, D.C. 20210

Dear Claimant,
Our records indicate that within the last 14 months, you requested approval for oxygen equipment
and/or accessories from the Division of Energy Employees Occupational Illness Compensation
(DEEOIC). We are very interested in receiving feedback on your experience with DEEOIC. Your
participation in the enclosed Customer Experience Survey will help us improve the claimant/customer
experience. We appreciate your assistance in helping us determine what is working and what may be
improved.
When completing the survey, please base your ratings on interactions with DEEOIC only, and not
medical providers, home health care agencies, authorized representatives, or other parties not
affiliated with DEEOIC.
The following survey is confidential. Please return this survey using the enclosed postage paid envelope
by XX/XX/2023. Thank you for your participation.
Stakeholder Engagement
Branch of Outreach and Technical Assistance
Division of Energy Employees Occupational Illness Compensation

U.S. Department of Labor
DEEOIC CUSTOMER
EXPERIENCE SURVEY

Over

Office of Workers’ Compensation Programs
Division of Energy Employees Occupational Illness Compensation
200 Constitution Ave, NW, Room C-3510
Washington, D.C. 20210

The OMB control number for this collection is 1225-0093 and expires on 02/29/2024. 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. The obligation to respond to this collection is voluntary. We estimate it takes about 6 minutes to complete this collection of information,
including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing the collection of information. Please send comments regarding the
burden estimate or any other aspect of this collection of information to the U.S. Department of Labor, DEEOIC, 200 Constitution Ave., NW, Room C-3510, Washington, D.C. 20210 and reference OMB
Control Number 1225-0093. Note: Please do not return the completed form to this address.

Please agree or disagree with the
following statements by circling a response:

Strongly
Agree
Agree

Neutral

Disagree

Strongly
Disagree

N/A

I am sa sfied with the service I received from the Division of Energy Employees Occupa onal
Illness Compensa on (DEEOIC) related to my oxygen equipment and/or accessories request.

5

4

3

2

1

n/a

The process leading up to receiving a decision on my oxygen equipment and/or accessories
request increased my trust in DEEOIC.

5

4

3

2

1

n/a

I have been able to get my ques ons about oxygen equipment and/or accessories requests
answered.

5

4

3

2

1

n/a

It was easy to complete what I needed to do to receive a decision on my request for oxygen
equipment and/or accessories.

5

4

3

2

1

n/a

It took a reasonable amount of me to receive a decision on my request for oxygen
equipment and/or accessories.

5

4

3

2

1

n/a

I understood what was being asked of me throughout the process of reques ng oxygen
equipment and/or accessories

5

4

3

2

1

n/a

The DEEOIC employees I interacted with during my oxygen equipment and/or accessories
request were helpful.

5

4

3

2

1

n/a

I feel comfortable talking with DEEOIC representa ves about the unique issues I face.

5

4

3

2

1

n/a

I am treated fairly by DEEOIC representa ves.

5

4

3

2

1

n/a

All medical expenses are subject to the OWCP Fee Schedule, including those out‐of‐pocket
medical expenses incurred by you. Were you aware of the OWCP Fee Schedule before taking
this survey?

Yes

No

Would you like the op on to access educa onal materials and handouts by scanning a QR
(Quick Response) code on your mobile device? (Scan the code on the right to be directed to the
Customer Experience page of the DEEOIC website)

Yes

No

Would you like to speak with our Customer Experience Team regarding your experience filing your request for oxygen equipment and/or accessories? Yes 

Open the camera application on
your mobile device, and then
bring this QR code into view.
You will have the option to click
the link which will bring you to
the DEEOIC CX website.
No 

If yes, please provide your name and telephone number. Please note that you will be receiving a call from a representa ve who will ask for your feedback on the process but cannot speak to specific
details about your case.
d
Name:___________________________ Phone:___________________________
OMB Control Number: 1225-0093
Expiration Date: 02/29/2024

U.S. Department of Labor

Office of Workers’ Compensation Programs
Division of Energy Employees Occupational Illness Compensation
200 Constitution Ave, NW, Room C-3510
Washington, D.C. 20210

When considering your oxygen equipment and/or accessories request experience from start to finish, please list or describe the “pain points” and “bright spots”
of your experience. (A pain point is interacƟon or step in the process that caused a problem, frustraƟon, or resulted in a negaƟve experience. A bright spot is an
interacƟon or step in the process that went smoothly, or resulted in a posiƟve experience.)
Pain Points:

Bright Spots:

EQUITY ASSESSMENT
Crea ng equity in our program means recognizing that different people have different circumstances. Some people face condi ons and circumstances that make it more difficult to
achieve the same goals.
“Equity data” describes aspects of your personal iden ty. DEEOIC does not collect this type of data, however we want to know if you feel like your own personal
circumstances have made it difficult for you to navigate this program.
OWCP/DEEOIC is commi ed to finding ways to focus on equity for all, including people who have been historically marginalized or adversely affected by inequality. We strive to
best serve all our customers, including racial and ethnic minori es, persons with disabili es, the LGBTQ+ community, rural communi es, and other underserved popula ons.
We want to improve program accessibility and inclusion.

Keeping the above informaƟon in mind, please
indicate if you’ve experienced challenges with our
program because of your:

Ability or disability status
Racial or ethnic iden ty
Age
Sex/Gender iden ty
Sexual orienta on
Veteran status
Religion
Social class
Geographic loca on (rural/remote)
Other________________

Based on your selecƟon(s) to the leŌ, how can DEEOIC beƩer
address your specific needs?











OMB Control Number: 1225-0093
Expiration Date: 02/29/2024