Supplemental Supporting Statement OWCP DCMWC Customer Experience Survey for Feedback on Claimants who Recently Received a Decisi

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: OWCP DCMWC Customer Experience Survey for Feedback on Claimants who Recently Received a Decision.

PURPOSE OF COLLECTION:

Paper survey designed to identify pain and positive points of our customers experienced in the claim process and 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 back on the paper survey, they will receive a call back. Their concerns and/or comments will be documented on the survey analysis.

3. Who will you collect the information from?

The Black Lung Program will collect information from 500 claimants who recently received a decision.

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?

• 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.

• One 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 they experienced difficulties in their interactions with the Federal Black Lung program. If the respondent responds yes to this question, they are prompted to identify the area/s of difficulty by checking the box/es in the list of options provided or writing in their response in the space beside the “other” box. They will be asked to explain how the check areas contributed to the difficulties in the application process in an explanation box.

6. Please provide your question list.

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

See attachments.

7. When will the activity happen?

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 announcing 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
Individuals or Households	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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