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 claimants who recently received medical travel reimbursement.

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

TYPE OF ACTIVITY: (Check one)

[ ] Customer Research (Interview, Focus Groups) [ X ] Customer Feedback Survey

[ ] User Testing

ACTIVITY DETAILS

1. How will you collect the information? (Check all that apply) [ ] Web-based or other forms of Social Media

[ ] Telephone [ ] In-person [ X ] Mail

[ ] Other, Explain

2. Who will you collect the information from?

DEEOIC will collect information from active claimants who received medical travel reimbursement from DEEOIC.

3. 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.

4. 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 equity assessment), and a section where respondents can provide their name and phone number for a call back. There are seven questions that seek a 1-5 Likert scale response, three multiple choice questions with checkbox-response options, three open-ended response questions, and one yes/no question.

5. Please provide your question list.

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

Survey attached.

6. When will the activity happen?

DEEOIC will send surveys to claimants during the 4th quarter of FY 2024.

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

[ ] Yes [ X ] No

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden Hours
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 and do not raise issues of concern to other Federal agencies;

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. Upon agreement between OMB and the agency aggregated data may be released as part of A-11, Section 280 requirements only on performance.gov. Summaries of customer research and user testing activities may be included in public-facing customer journey maps.

8. Additional release of data will be coordinated with OMB.

Name: Benjamin Kistler

Email: [email protected]

All instruments used to collect information must include: OMB Control No. 1225-0093

Expiration Date: 01/31/2027

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