Template - Section 504 Self-Evaluation Survey

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

T ITLE OF INFORMATION COLLECTION Section 504 Self-Evaluation Survey on Individuals with Mental or Cognitive Disabilities

PURPOSE:

Under section 504 of the Rehabilitation Act of 1973, as amended, Federal agencies are required to provide meaningful access to their programs and facilities to individuals with disabilities.

Section 504 protects qualified individuals with disabilities. Under this law, individuals with disabilities are defined as persons with a physical or mental impairment that substantially limits one or more major life activities. To assist us in meeting the Section 504 requirements, SSA is conducting a self-evaluation of the accessibility of our programs, activities, and facilities to individuals with disabilities. The self-evaluation consists of a plan to determine whether our current programs and activities discriminate or have the effect of discriminating based on disability, and whether the facilities and places where we conduct our programs and activities are accessible to persons with disabilities. Once the self-evaluation is complete, and to the extent modifications of any of these policies and practices are required, we plan to take the necessary corrective actions.

SURVEY:
We provided opportunities for interested persons to participate in the self-evaluation process through two Federal Register Notices (FRN) posted on the regulations.gov website. In addition to the FRNs, we held two public forums where individuals registered to present in person and over the phone.

This webinar is one in a series of webinars SSA plans to broadcast to solicit feedback from the public and advocacy groups. This particular webinar seeks to collect feedback on access to individuals with mental or cognitive impairments. After viewing the 20-minute webinar, we invite the public to answer a series of questions on how SSA can effectively communicate with individuals with mental and cognitive disabilities.

The objective of the questions included in the survey is to gather feedback from the public and advocacy groups to help us with the Section 504 self-evaluation. The topic for this webinar is “Communicating Effectively with Individuals with Mental and Cognitive Disabilities.”

Webinar viewers can access the survey from www.socialsecurity.com. The link takes them to the webinar through York Telecom, SSA’s contractor for webinars. The website will contain a survey link that transmits the responses electronically to an SSA mailbox. SSA conducts this survey without assistance from the contractor.

DESCRIPTION OF RESPONDENTS:

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, 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 [ ] No N/A

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 (minutes)	Burden (hours)
Focus group participants	25	10	4
Totals	25	10	4

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? [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?

SSA keeps a list of business contacts routinely used to notify organizations of communication events. In this instance, we will notify organizations representing the mentally or cognitively disabled of the webinar via email. We will ask the organizations to share the information with their constituents and other organizations. The email will contain a link to an RSVP form. The RSVP form collects only whether or not individuals will watch the webinar and their email address if they want SSA to send a reminder to them.

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

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

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