Voluntary Demographic Information

OMB Control Number: 1225-0093

Expiration Date: 02/29/2024

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 obligation to respond to this collection is voluntary. We estimate it takes about 5 minutes to complete.

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