Survivor Survey

Request for Approval under the “Generic Clearance for Improving
Customer Experience: OMB Circular A-11, Section 280
Implementation”
(OMB Control Number:2900-0876)
TITLE OF INFORMATION COLLECTION: Survivor Survey
PURPOSE OF COLLECTION:
The Veterans Benefits Administration (VBA) is responsible for
providing and/or managing a wide array of services to Veterans
and their family members. The Office of Survivors Assistance
(OSA)serves as a resource for all benefits and services
furnished to eligible spouses and dependents of deceased
Veterans and Service members.
OSA currently does not have a standardized ability to capture
and use customer feedback at outreach events. The Veterans
Experience Office (VEO) in partnership with OSA will leverage
VSignals to collect feedback through a short, low burden
customer service survey delivered as a URL/QR code for
distribution to event attendees. OSA will use the feedback
received to measure survivor sentiment and trust surrounding
their experience applying for and accessing benefits and
services from VA.
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?
[ ] 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
[ ] Mail
[ X] Other, the survey will be delivered as a URL/QR code
for distribution to event attendees
3. Who will you collect the information from?
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The target audience will be attendees at events where OSA is
present which will include spouses and dependents of deceased
Veterans and Service members.
4. How will you ask a respondent to provide this information?
Attendees at OSA attended events will be provided the survey
through a link/QR code.
5. What will the activity look like?
The survey will consist of 15 questions. Attendees at events
where OSA is present will be offered the opportunity to complete
a survey through a link/QR code. The survey will be completed
using an using an online interface. The survey itself will
consist of questions revolving a human-centered design focusing
on such elements as trust, emotion, and east of the interaction.
6. Please provide your question list.
See attached.
Please make sure that all instruments, instructions, and scripts
are submitted with the request.
7. When will the activity happen?
The activity will happen throughout the year at outreach events
attended by the OSA.
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
Survivor Survey

No. of
Respondents
1,000

Totals

1,000

Participation
Time
5 minutes
5 minutes

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

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Burden
Hours
83
83

3.
4.
5.
6.
7.

8.

respondent) and are low-cost for both the respondents and the
Federal Government;
The collections are non-controversial;
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;
Personally identifiable information (PII) is collected only to
the extent necessary and is not retained;
Information gathered is intended to be used for general
service improvement and program management purposes
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.
Additional release of data will be coordinated with OMB.

Name and email address of person who developed this survey/focus
group/interview:
Name: Juan Jackson
Email address: [email protected]
All instruments used to collect information must include:
OMB Control No. 2900-0876
Expiration Date: 02/28/2026

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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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