Template - Appointed Rep Survey (Interview)

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

T ITLE OF INFORMATION COLLECTION: Appointed Representative Survey

The Social Security Administration (SSA) requires claimants’ appointed representatives to use our electronic services, iAppeals, to file a reconsideration request on a client’s behalf. The majority of appeals filed electronically via iAppeals are submitted by attorney and non-attorney appointed representatives.

SSA would like to garner feedback from these appointed representatives who currently use or have used the iAppeals application. We believe an opportunity to do so will occur at an upcoming conference of the National Association of Disability Representatives (NADR). SSA representatives will visit the conference to conduct interviews with appointed representatives to capture their opinions on the internet user experience of the existing iAppeals application.

Meeting face-to-face with representatives at the conference allows SSA to collect information from those representatives who would ordinarily not schedule a telephone or face-to-face conference with SSA staff. We will ask conference attendees their opinions of the existing application and suggestions for improvements.

Participant feedback will assist SSA in prioritizing improvements to the iAppeals application.

DESCRIPTION OF RESPONDENTS: Attorney and non-attorney appointed representatives and staff members, the majority of whom have used the iAppeals application.

TYPE OF COLLECTION: (Check one)

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

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

[] Focus Group [X] Other: Individual interviews ______________________

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_________

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

4. 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)
Individuals (attorney and non-attorney appointed representatives, possible staff members of appointed representatives)	36	30	18
Totals	36		18

FEDERAL COST: The estimated annual cost to the Federal Government is __$4000__________

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 conference host, NADR, has agreed to solicit conference attendees to participate in the voluntary interviews while attending the conference. SSA representatives will speak with conference attendees interested in participating, and schedule an interview with those attendees who meet the participant criteria (e.g., appointed representatives {or their staff} who use or have used iAppeals).

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[X ] In-person

[ ] Mail

[ ] Other, Explain

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

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

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