Access Survey Template

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

TITLE OF INFORMATION COLLECTION: Jackson Federal Building Access Survey

PURPOSE:

Determine public experience with locating and accessing services at the Social Security Administration (SSA) office located at the Jackson Federal Building, Seattle, Washington. Members of the community have expressed concern about getting to the building, accessing the building, and finding the SSA office after entering the building.

SSA would like to survey members of the public who have recently visited the Jackson Federal Building with the hope of understanding any difficulties they may have encountered accessing the building and finding the office located within the building. We purpose to conduct a survey questionnaire using SSA-approved interviewers.

DESCRIPTION OF RESPONDENTS: Visitors (individuals/public) to the Social Security office at the Jackson Federal Building in Seattle, Washington.

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 questions:

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

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	30	5	3
Totals	30	5	3

FEDERAL COST: The estimated annual cost to the Federal government is ___$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? [ ] Yes [x ] 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?

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

3