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 Resource Center Customers.

PURPOSE OF COLLECTION:

This is a revision to an existing paper survey designed to gather feedback from customers visiting Resource Centers that assist claimants filing under the Energy Employees Occupational Illness Compensation Program Act (EEOICPA). This revision will make sure that the survey aligns with the new A-11 Section 280 guidelines. The survey is offered to stakeholders who complete an in-person visit at one of the 11 Resource Centers throughout the country. There is also a translated version of this survey for Spanish speaking stakeholders.

TYPE OF ACTIVITY:

[ ] 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?

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ X ] In-person

[ ] Mail

[ ] Other, Explain

3. Who will you collect the information from?

DEEOIC stakeholders who visit Resource Centers in-person (generally claimants and Authorized Representatives).

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

Respondents will be offered the opportunity to fill out a paper survey following their in-person visit. They may submit the survey on site. In rare cases where the respondent does not want to turn the survey in on-site, they will be offered a postage paid envelope that they can choose to mail directly to the DEEOIC National Office.

5. What will the activity look like?

Respondents are offered a 1-page paper survey to fill out. The survey contains 11 questions, 3 of which are multiple choice, 7 of which are a 1-5 response, and 1 open-response. 

6. Please provide your question list.

Survey is attached.

7. When will the activity happen?

Surveys will be distributed continuously as stakeholders visit Resource Centers. 

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
Resource Center Visitors (claimants and Authorized Representatives)	1500	5	125
Totals			125

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: 01/31/2027

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