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: Customer Experience Survey for feedback on claimants with a pending claim.

PURPOSE OF COLLECTION:

Paper survey designed to identify pain and positive points of our customers at different stages in the claim process. To determine if Black Lung claimants are utilizing the C.O.A.L. (Claimant Online Access Link. We will use this information to improve our claimant experience.

TYPE OF ACTIVITY: (Check one)

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

[ ] 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?

[ ] Yes

[ X ] No

[ ] Not a survey

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ X ] Mail

[ X ] Other, Explain - If customer request a call they will receive a call back and their concerns and/or comments will be documented.

3. Who will you collect the information from?

The Black Lung Program will collect information from 500 claimants in different stages of the claim process; 250 claimants will be pre-SSAE (Schedule for Submission of Additional Evidence) with no preliminary determination issued yet and 250 claimants will be post-SSAE with a preliminary determination on record, but no Proposed Decision and Order (PDO) issued yet.  Those in the pre-SSAE category would have received an initial development letter (requesting additional info or stating no additional info needed at this time) and medical authorization to schedule their DOL sponsored pulmonary evaluation.

At the District Office level there are two decisions rendered – Schedule for Submission of Additional Evidence (SSAE) and Proposed Decision and Order (PDO).  The SSAE is a preliminary determination that is made based on the evidence of record at the time.  That decision, which includes dependency, employment evidence, liability determination, and DOL sponsored complete pulmonary evaluation, provides all parties with set timeframes in which to submit new evidence and/or rebuttal evidence.  Once those established timeframes have expired, the PDO is issued either affirming or reversing the SSAE determination. The PDO can then be appealed to the Office of Administrative Law Judges (OALJ).

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

The respondent will be asked to complete the paper survey form and mail it back in the business return envelope provided within 30 days.

5. What will the activity look like?

Describe the information collection activity – e.g. what happens when a person agrees to participate? Will facilitators or interviewers be used? What’s the format of the interview/focus group? If a survey, describe the overall survey layout/length/other details? If User Testing, what actions will you observe / how will you have respondents interact with a product you need feedback on?

• The mailed package will include a cover letter explaining the purpose of the collection.

• The Survey will consist of 5 customer experience questions in which the claimant will have the option to select from Strongly Agree, Agree, Neutral, Disagree, Strongly Disagree, or N/A. Claimants also have space to provide additional information on the questions.

• Question about the C.O.A.L Portal (Claimant Online Access Link) will give the Black Lung Program a better understanding of the percentage of claimants that use the portal and if not why. This question gives respondents multiple options to select from.

- One Question in the Barriers to Access Survey section. One question asking if in their interactions with the Federal Black Lung program, have they experienced difficulties due to different factors. If the respondent responds yes to this question, they are prompted to check options provided or space is provided if the option is not listed. They will be asked to explain how the check areas contributed to the difficulties in the application process in an explanation box.

• Space for Other General Comments or Suggestions for improving our Service.

• Yes or no question asking if they would like to talk to a Federal Black Lung Representative

6. Please provide your question list.

Paste here the questions or prompts presented to participants in your activity. If you have an interview / facilitator guide, that can be attached to the submission and referenced here.

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

See attachments.

7. When will the activity happen?

Describe the time frame or number of events that will occur (e.g., We will conduct focus groups on May 13,14,15, We plan to conduct customer intercept interviews over the course of the Summer at the field offices identified in response to #2 based on scheduling logistics concluding by Sept. 10^th, or “This survey will remain on our website in alignment with the timing of the overall clearance.”)

The survey will be mailed as soon as possible after approval. An email will be sent to Black Lung staff letting them know the survey is being sent out to customers in case they receive calls about the survey. A post regarding the survey will be made on the DCMWC website.

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
	500	5 Minutes	42
Totals	500	5 Minutes	42

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: Kenny Lowe, Equity Coordinator

Email address: [email protected]

All instruments used to collect information must include:

OMB Control No. 1225-0093

Expiration Date: 01/31/2027

HELP SHEET

(OMB Control Number: XXXX-XXXX)

TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)

PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.

TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.

CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.

Personally Identifiable Information: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.

BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected per row.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.

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