Survey Template

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0960-0788)

T ITLE OF INFORMATION COLLECTION: Video Remote Interpreting Electronic Bulletin Board Discussion Group

PURPOSE:

SSA is the largest provider of services to the aging population and persons with disabilities in the country. SSA strives to ensure these services are easily accessible to claimants, beneficiaries, and employees. We recognize the transformative power of technology to assist users, whether disabled or not, in obtaining SSA services, and whether people choose to interact with SSA in person, over the phone, or via the internet.

Section 504 of the Rehabilitation Act of 1973, mandates SSA to ensure that a deaf or hard of hearing (DHOH) individual has meaningful access to SSA programs, activities, and facilities. SSA would like to conduct a qualitative recipient access survey with DHOH individuals about their experience with SSA, and to learn how SSA can provide them greater accessibility to our current services, while maintaining standards for everyone.

Goals and Objectives:

To garner feedback from DHOH SSA customers who require a reasonable accommodation of a sign language interpreter and have used the VRI service.

We are seeking feedback to:

• Determine user satisfaction with the VRI picture quality;

• Determine user satisfaction with the quality of the video interpreters;

• Determine user satisfaction with the VRI service wait time;

• Determine what, if any, issues the user encountered with the service and if so, if the issue was resolved; and,

• Ascertain overall user satisfaction with the VRI service.

DESCRIPTION OF RESPONDENTS: Individuals who are deaf or hard of hearing; have used SSA’s video remote interviewing service; comfortable with using the Internet; representative mix in terms of race, gender, income and education (see below for more detail on participants/respondents).

TYPE OF COLLECTION: (Check one)

[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [X ] Small Discussion Group

[] Focus Group [ ] Other: ______________________

CERTIFICATION:

I certify the following to be true:

1. The collection is voluntary.

2. The collection is low-burden for respondents and low-cost for the Federal Government.

3. The collection is non-controversial and does not raise issues of concern to other Federal agencies.

4. The results are not intended to be disseminated to the public.

5. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

6. The 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 future.

Name: Faye Lipsky, Reports Clearance Officer, Social Security Administration

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ ] Yes [X ] No

2. If Yes, is the information that will be collected included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ X ] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ X ] Yes, $75 per participant. [ ] No Respondents will not be paid for their participation.

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time (minutes)	Burden (hours)
Individuals	40	120	80
Totals	40	120	80

FEDERAL COST: The estimated annual cost to the Federal Government is $4,100.

If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:

The selection of your targeted respondents

1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe? [ X] Yes [ ] No

If the answer is yes, please provide a description of both below (or attach the sampling plan). If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?

The participant selection criterion for this research is as follows:

• Deaf or hard of hearing individuals;

• Used the video remote interpreting service at one of 37 SSA field offices offering this service;

• Comfortable with using the internet; and,

• A representative mix in terms of race, gender, income and education.

Administration of the Instrument

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

[X ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain - Survey Sheet/Questionnaire

2. Will interviewers or facilitators be used? [ X ] Yes [ ] No

How will we conduct the survey?

We will conduct two electronic bulletin board discussion group sessions via online.

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

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