Template - Survey Description Federal Feedback Button Pilot Customer Satisfaction Survey

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

TITLE OF INFORMATION COLLECTION: Federal Feedback Button (FFB) -- SSA Pilot Survey

PURPOSE:

This is an OMB sponsored project managed by the General Services Administration (GSA). OMB and GSA are looking for partner agencies to pilot the Federal Feedback Button – a simple tool to collect customer feedback and:

• Provide agencies with information needed to improve program delivery;

• Provide the Executive Branch with insight into best practices and areas to improve; and

• Provide the public with transparency around the quality of services provided.

We purpose to engage the public for feedback on their experience on services provided at our Social Security Card Centers (SSCC).

For this survey, we will use kiosks stationed at each of our 14 SSCCs. We will also use an optional website to garner public feedback. We will ask only one question at the kiosk. The kiosk is a simple electronic device with one question listed at the top of its screen. The respondent’s response is a series of four smiley-face emoticons. Respondents can option to use a website in lieu of the kiosk. We will also ask only one question on the website with the same four smiley-face emoticon responses. However, in addition to the one question on the website, we will provide a free-form text box for any additional information respondents would like to provide on their own.

Survey Details

Who will conduct the survey? SSA working with GSA.

Where will we conduct the survey? We will conduct the survey at each of our 14 SSCC. We purpose to install one kiosk at each SSCC. When individuals complete their business with SSA, an SSA employee will inform them they have the option of providing feedback on their experience. The individual can voluntarily enter their feedback by either using the SSCC on-site kiosk or go to a website (URL address provided by the SSA employee) to answer the same question with the additional option to provide free-form text on the website.

When will we conduct the survey ? For one year beginning in July 2015.

DESCRIPTION OF RESPONDENTS:

The respondents are members of the public who come to a SSCC to obtain either an original or a replacement Social Security card.

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

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [X ] No

BURDEN HOURS (per month)

Category of Respondent	No. of Respondents	Participation Time (Minutes)	Burden (hours)
Kiosk	1,200	1	20
Internet Website	120	3	6
Totals	1,320		26

FEDERAL COST: The estimated annual cost to the Federal government is ____0________

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?

We plan to inform members of the public who come to a SSCC that they have the option to answer a one-question customer satisfaction survey via a kiosk in the SSCC. They can also go to a specialized website to answer the question.

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

[ X ] Other: Self standing kiosk

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

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

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