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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” HHS Online Customer Surveys (OMB Control Number: 0990-0379)

TITLE OF INFORMATION COLLECTION: User feedback for the Benefit Cliff Calculator

PURPOSE: The Office of the Assistant Secretary for Planning and Evaluation is developing a Benefit Cliff Calculator that will help users calculate their effective marginal tax rates, that is, how much of additional earnings would be “retained” after considering taxation and potential reductions in government benefits. The purpose of collecting feedback from users of the calculator is to better understand whether users find the tool to be easy to use, and whether the information provided by the tool is helpful for household decision-making. The purpose of the tool is to provide users with useful information, so the ease of use and helpfulness of the information provided by the tool is critical to help users make informed decisions about earnings increases and net family resources.

DESCRIPTION OF RESPONDENTS: The Benefit Cliff Calculator will be located on the websites of the following local/state governments: New Hampshire, Maine, District of Columbia, and Alleghany County, Pennsylvania. Therefore, targeted respondents will be residents of those states/cities/counties who receive one or more government benefits. Caseworkers from these jurisdictions will also use the Calculator. Respondents will first use the Benefit Cliff Calculator, then, at the conclusion of using the Calculator, respond to user feedback items.

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:__Nina Chien______________________________________________

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 NOT APPLICABLE

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ ] No NOT APPLICABLE

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 hour
Case Workers	200	4/60	13.3
Benefit recipients	200	3/60	10
Totals	400		23.3

Please note that the survey contains 4 items for respondents who are benefit recipients and 5 items for respondents who are caseworkers, for a total of 9 items. However, all respondents will only answer 4 or 5 items (no respondent will answer all 9 items).

FEDERAL COST: The estimated annual cost to the Federal government is _$15,000___________

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?

All users of the Benefit Cliff Calculator will be invited to respond to the customer satisfaction survey, upon completion of the use of the Calculator.

Targeted persons to use the Calculator will be government benefit recipients and case workers in New Hampshire, Maine, the District of Columbia, and Alleghany County, PA. To recruit individuals to use the Benefit Cliff Calculator, we will disseminate information about the Calculator using social media messages, email blasts, newsletter posts, webinars, videos, podcasts, and testimonials. The dissemination strategy will also leverage existing relationships with state/county partners, such as identifying individuals in partnering agencies highly interested in using the tool and training others in their agency.

The Calculator will reside on a public-facing website, so any individual with internet access will be able to access the Calculator.

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

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

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