Survey Template

Survey Template Final.doc

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery (Fast Track)

Survey Template

OMB: 0960-0788

Document [doc]
Download: doc | pdf



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



TITLE OF INFORMATION COLLECTION: Customer Satisfaction Survey for Registration, Personalized Portal, and the Online Social Security Statement (Social Security employees)

Purpose:

The Social Security Administration (SSA) will be deploying an online process where members of the public are able to register, view their personal information, and both view and print their Social Security statement (Statement) online. (OMB-approved information collection request, OMB Number 0960-0789, SSA’s Public Credentialing and Authentication Process {PCAP}.)


We will be asking for volunteers from SSA employees nationwide to complete the PCAP online registration process, review their personal information, and access their Statement as members of the public. Excluding the survey questionnaire, this activity (the registration process, access to, and reviewing personal information) mirrors the actual PCAP as intended for the public.


We will collect information from the participants to document the user experience with the PCAP functionality including accuracy of the information displayed, ease of use, and measuring overall customer satisfaction. We will use this information to evaluate and improve the PCAP user experience.


DESCRIPTION OF RESPONDENTS:

Social Security Administration employees nationwide who have volunteered to participate as members of the public.


TYPE OF COLLECTION: (Check one)

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

[ ] Usability Testing (e.g., Website or Software) [ ] 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, SSA Reports Clearance Officer


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? [ ] Yes [x ] No


BURDEN HOURS:

Category of Respondent

No. of Respondents

Participation Time

Burden

Federal Government

300

10 minutes

50 hrs





Totals

300

10 minutes

50 hrs


FEDERAL COST:

There is no cost to the Federal Government.


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? [ ] Yes [x ] No


  1. 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?


We plan to solicit Social Security regions nationwide and Social Security headquarters employees for volunteers to serve as members of the public.


Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ x ] Other, Explain – We will disseminate the survey using email and collect the findings using a web-based survey.


  1. Will interviewers or facilitators be used? [ ] Yes [x ] N

File Typeapplication/msword
File TitleSAMPLE CLEARANCE FORMAT – use “Basic Elements Template” for guidance on completing this form
Author666429
Last Modified By889123
File Modified2011-12-27
File Created2011-12-27

© 2024 OMB.report | Privacy Policy