Authorized Representative Survey Supporting Statement

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: Paper Survey for Soliciting Feedback for Division of Energy Employees Occupational Illness Compensation (DEEOIC)from Authorized Representatives

PURPOSE OF COLLECTION:

Paper survey designed to gather feedback from Authorized Representatives under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA). Soliciting feedback on what the program does well, if there are any areas for improvement, and an overall idea of how well we serve our stakeholders in this area. We will use the information to improve our Authorized Representatives’ experiences and identify potential areas for improvement and/or training. We will report the findings of our survey on the Performance.gov website.

TYPE OF ACTIVITY: (Check one)

[ ] Customer Research (Interview, Focus Groups, Surveys)

[ X ] Customer Feedback Survey

[ ] Usability Testing of Products or Services

ACTIVITY DETAILS

1. If this is a survey, will the results of this survey be reported to Touchpoints as part of quarterly reporting obligations specified in OMB Circular A-11 Section 280?

[ X ] Yes

[ ] No

[ ] Not a survey

2. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[ X ] Telephone

[ ] In-person

[ X ] Mail

[ ] Other, Explain

3. Who will you collect the information from?

DEEOIC will collect information from active Authorized Representatives who represent EEOICPA claimants.

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

DEEOIC will send surveys via U.S. mail and will include a postage-paid return envelope. Respondents have the option to request a follow up telephone call to discuss their experience more in-depth.

5. What will the activity look like?

The mailed package will include a cover letter explaining the purpose of the collection, and a survey with 14 questions (including 2 comment boxes), and an optional section where they can include their name and phone number for a call back. Ten questions are scored on a 1-5 Likert scale response, one is a checkbox, one is a multiple choice, and the last two are open response.

6. Please provide your question list.

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

Survey language attached.

7. When will the activity happen?

DEEOIC will send surveys to the identified Authorized Representatives during the early 2^nd quarter FY24.

8. Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants?

[ ] Yes [ X ] No

If Yes, describe:

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden Hours
Authorized Representatives for Claimants	2,000	5 Minutes	167
Totals			167

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;

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. The agency will follow the procedures specified in OMB Circular A-11 Section 280 for the required quarterly reporting to OMB of trust data and experience driver data from surveys.

8. Outside of the quarterly reporting mentioned in the bullet immediately above, if the agency intends to release journey maps, user personas, reports, or other data-related summaries stemming from this collection, the agency must include appropriate caveats around those summaries, noting that conclusions should not be generalized beyond the sample, considering the sample size and response rates. The agency must submit the data summary itself (e.g., the report) and the caveat language mentioned above to OMB before it releases them outside the agency. OMB will engage in a passback process with the agency.

Name and email address of person who developed this survey/focus group/interview:

Name: Allison Spencer

Email address: [email protected]

All instruments used to collect information must include:

OMB Control No. 1225-0093

Expiration Date: 02/29/2024

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