Form FEMA Form-104-FY-2 FEMA Form-104-FY-2 Proof of Loss Survey -Phone

OMB No. 1660-0130

Expiration: 06/30/2028

PAPERWORK BURDEN DISCLOSURE NOTICE

                                                        FEMA Form-104-FY-24-118     

Public reporting burden for this data collection is estimated to average 5-7 minutes per response. The burden estimate includes the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and submitting this form. You are not required to respond to this collection of information unless a valid OMB control number is displayed on this form. Send comments regarding the accuracy of the burden estimate and any suggestions for reducing the burden to: Information Collections Management, Department of Homeland Security, Federal Emergency Management Agency, 500 C Street. SW, Washington, DC  20472-3100, Paperwork Reduction Project (1660-0130) NOTE: Do not send your completed form to this address.

PRIVACY ACT STATEMENT

AUTHORITY: Government Performance and Results Act of 1993 (Pub. L. 103-62), as amended, and the GPRA Modernization Act of 2010 (Pub. L. 111-352); Executive Order (EO) 12862, “Setting Customer Service Standards”; and its March 23, 1995 Memorandum addendum, “Improving Customer Service”; Executive Order 13411 “Improving Assistance for Disaster Victims”; Executive Order 13571 “Streamlining Service Delivery and Improving Customer Service”; and the related June 13, 2011 Memorandum “Implementing Executive Order 13571 on Streamlining Service Delivery and Improving Customer Service.”

PRINCIPAL PURPOSE(S): DHS/FEMA collects this information to measure Hermit’s Peak/Calf Canyon claimant satisfaction with Claims Office services.

ROUTINE USES:

This information is used for the principal purpose noted above. Summary and/or aggregate survey results and analysis may be shared with Congress and the Government Accountability Office; however, no Personally Identifiable Information (PII) will be shared externally, except as allowed under the routine uses published in System of Records Notice DHS/FEMA-008 - Disaster Recovery Assistance Files, 78 FR 25282 (April 30, 2013), or as required by law. The Department's system of records notices can be found on the Department's website at http://www.dhs.gov/system-records-notices-sorns.

DISCLOSURE: The disclosure of information on this form is strictly voluntary and will assist the Hermit’s Peak/Calf Canyon Claims Office in making improvements to its Claims program; failure to provide the information requested will not impact an individual’s ability to qualify for or receive Claims Office assistance. Questions regarding this form may be submitted via email to FEMA-CSA-Survey@fema.dhs.gov.

Introduction – Phone Survey (Where Claim Type = Individual)

Hello, I’m calling from FEMA, the Federal Emergency Management Agency. My name is _______ and my PIN is ____. May I please speak with [Claimant name]?

Introduction – Phone Survey (Where Claim Type = Business, Government, Tribal, or Not-for-Profit and the Name field does not include a person’s name )

Hello, I’m calling from FEMA, the Federal Emergency Management Agency. My name is _______ and my PIN is ____. May I please speak with the person most familiar with the Hermits Peak/Calf Canyon Claim? [Claimant name]?

If no: Thank you for your time and have a good day/evening.

If yes: You recently submitted a Proof of Loss (POL) with the Hermit’s Peak/Calf Canyon Claims Office. You may still be discussing other losses with Claims Office staff, but we would like to know how the process is going for you. This confidential survey helps the Claims Office make sure your needs are heard and continuously improve our process. Please think about your experience so far with the Claims Office when answering the following questions Would you volunteer to take 5-7 minutes to answer some questions?

If no: What would be a better time to call back? Thank you for your time and have a good day/evening.

If yes: These questions comply with the Privacy Act of 1974 and have been approved by the Office of Management and Budget under number 1660-0130. Your answers will not affect the outcome of your claim. This call may be monitored and/or recorded for quality assurance.

EXPERIENCE WITH CLAIMS OFFICE STAFF

The first questions are about your experience in working with Claims Office staff to create your Proof of Loss (POLs). Using a scale of 1 (Not at all Satisfied) to 5 (Very Satisfied), please rate Claims Office staff on the following…

	1 Not at all Satisfied	2	3	4	5 Very Satisfied
Explaining the documents you will need to submit	◘	◘	◘	◘	◘
Explaining how the claims office can support you in gathering documentation and valuing your losses	◘	◘	◘	◘	◘
Explaining why you are signing forms	◘	◘	◘	◘	◘
Responding in a timely manner	◘	◘	◘	◘	◘
Informing you what happens after you submit your Proof of Loss (POLs)	◘	◘	◘	◘	◘
Understanding the overall Claims process	◘	◘	◘	◘	◘

ADVOCATE’S OFFICE

The Advocate’s Office provides support by advocating for claimants and potential claimants with compassion, equity, and fairness. The Advocate provides additional resources to help understand the process and provides timely and fair resolution of complex issues. Using a scale of 1 (Poor) to 5 (Excellent), or no experience…

	1 Poor	2	3	4	5 Excellent	No Experience
Please rate your experience with the Advocate’s Office	◘	◘	◘	◘	◘	◘

(Programmer note: If Q7 response = No Experience go to Q13, else go to Q8)

Thinking about working with the Advocate’s Office, using a scale of 1 (Poor) to 5 (Excellent), please rate them on…

	1 Poor	2	3	4	5 Excellent
8. Information provided	◘	◘	◘	◘	◘
9. Resolution of the issue(s)	◘	◘	◘	◘	◘
10. Helpfulness of staff	◘	◘	◘	◘	◘
11. Overall customer service	◘	◘	◘	◘	◘

(Programmer note: If Q8, 9, 10, or 11 response = 3 or <3 go to Q12.)

12. What suggestion do you have on ways the Advocate’s Office services could be improved?

CLAIMS OFFICE

You may have gone into a Claims Office to meet with Claims Office staff or to get information. Using a scale of 1 (Poor) to 5 (Excellent), or no experience…

	1 Poor	2	3	4	5 Excellent	No Experience
13. Please rate your overall satisfaction with the Claims Office	◘	◘	◘	◘	◘	◘

(Programmer note: If Q13 response = No Experience skip to 21, else go to Q14)

For the next questions please use a scale of 1 (Poor) to 5 (Excellent) or if you had no experience with that service say “No Experience". How would you rate the Claims Office on the following:

	1 Poor	2	3	4	5 Excellent	No Experience
14. Convenient in-person locations	◘	◘	◘	◘	◘	◘
15. Hours of operation	◘	◘	◘	◘	◘	◘
16. Provides easy to understand resources and materials about the claims process	◘	◘	◘	◘	◘	◘
17. Assistance provided in preferred language, including American Sign Language.	◘	◘	◘	◘	◘	◘
18. Handicap accessible	◘	◘	◘	◘	◘	◘
19. Protecting your privacy while working with the Claims Office	◘	◘	◘	◘	◘	◘

20. Which one of the following was your main source of information about Claims Office locations and services?

◘ Community group like church, school, volunteer fire stations, Post Office, senior center, restaurants, community meeting

◘ Flyers, signs, billboards, posters

◘ Newspaper, radio, television

◘ Word of mouth from friends, family, neighbors, employer, landlord

◘ Claims Office website

◘ State or Local Government websites or notices

◘ Social media

ONLINE INFORMATION

You may have used online sources such as the Claims office website to receive information. Using a 1 (Poor) to 5 (Excellent), or no experience…

	1 Poor	2	3	4	5 Excellent	No Experience
21. How would you rate your online experience with the Claims Office website information	◘	◘	◘	◘	◘	◘

(Programmer note: If Q21 response = No Experience go to Q27, else go to Q22)

The next questions are about using the official Claims Office website on FEMA.gov. Please use a scale of 1 (Not at all Easy) to 5 (Very Easy) or if you had no experience with that service say No Experience. How easy was…

	1 Not at all Easy	2	3	4	5 Very Easy	No Experience
22. Navigating the website	◘	◘	◘	◘	◘	◘
23. Finding forms	◘	◘	◘	◘	◘	◘
24. Finding helpful information	◘	◘	◘	◘	◘	◘
25. Reading Frequently Asked Questions (FAQs)	◘	◘	◘	◘	◘	◘
26. Learning about the program	◘	◘	◘	◘	◘	◘

You may have had experience with the Community Portal for the Claims Office. On a scale of 1 (Poor) to 5 (Excellent), or no experience…

	1 Poor	2	3	4	5 Excellent	No Experience
27. How would you rate your online experience with the Community Portal information	◘	◘	◘	◘	◘	◘

(Programmer note: If Q27 response = No experience go to Q30, else go to Q28)

The next questions are about using the Community Portal. Please use a scale of 1 (Not at all Easy) to 5 (Very Easy) or if you had no experience with that service say No Experience. How easy was…

	1 Not at all Easy	2	3	4	5 Very Easy	No Experience
28. It to create an account	◘	◘	◘	◘	◘	◘
29. It to check your claim status	◘	◘	◘	◘	◘	◘

You may have had experience with the Claims Office Facebook page. Using a 1 (Poor) to 5 (Excellent) scale, or no experience…

	1 Poor	2	3	4	5 Excellent	No Experience
30. How would you rate your online experience with the Claims Office Facebook page	◘	◘	◘	◘	◘	◘

(Programmer note: If Q30 response = No experience go to Q34, else go to Q31)

The next questions are about using the official Claims Office Facebook page. Please use a scale of 1 (Not at all Easy) to 5 (Very Easy) or if you had no experience with that service say No Experience. How simple was…

	1 Not at all Easy	2	3	4	5 Very Easy	No Experience
31. Finding helpful information	◘	◘	◘	◘	◘	◘
32. Seeing or reading notices of events	◘	◘	◘	◘	◘	◘
33. Keeping up to date on policy	◘	◘	◘	◘	◘	◘

Using a scale of 1 (Not at all Satisfied) to 5 (very satisfied), or no experience, how satisfied are you with …

	1 Not at all Satisfied	2	3	4	5 Very Satisfied	No Experience
34. Your overall online experiences	◘	◘	◘	◘	◘	◘

Closing

Thank you for your time. Have a good day/evening