Form 976 2015 976 CMS-CGS DME MAC B Questionnaire 6.9.16

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Overview

Welcome and Thank You Text
Current Model Qsts
Current Custom Qsts

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Sheet 1: Welcome and Thank You Text

Welcome and Thank You Text
	Welcome Text			Thank You Text
	Thank you for visiting CGS. You have been randomly selected to take part in this survey that is being conducted by ForeSee on behalf of CGS. Please take a minute or two to give us your opinions. The feedback you provide will help CGS enhance its site and serve you better in the future. All results are strictly confidential.			Thank you for your time in completing this survey. Your input is very valuable and will be taken into consideration.
	Welcome Text - Alternate			Thank You Text - Alternate

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Sheet 2: Current Model Qsts

Model Instance Name:
CMS - CGS DME MAC B
MID:
Partitioned (Y/N)?		YES - 2MQ
Date:		6/9/2016
CMS - CGS DME MAC B
Model questions utilize the ACSI methodology to determine scores and impacts
```	Label	Element Questions		Label	Satisfaction Questions		Label	Future Behaviors
		Content (1=Poor, 10=Excellent, Don't Know)			Satisfaction	19	Return	Return (1=Very Unlikely, 10=Very Likely)
1	Content - Accuracy	Please rate the accuracy of information on this site.	16	Satisfaction - Overall	What is your overall satisfaction with this site? (1=Very Dissatisfied, 10=Very Satisfied)			How likely are you to return to this site?
2	Content - Quality	Please rate the quality of information on this site.	17	Satisfaction - Expectations	How well does this site meet your expectations? (1=Falls Short, 10=Exceeds)	20	Recommend	Recommend (1=Very Unlikely, 10=Very Likely)
3	Content - Freshness	Please rate the freshness of content on this site.	18	Satisfaction - Ideal	How does this site compare to your idea of an ideal website? (1=Not Very Close, 10=Very Close)			How likely are you to recommend this site to someone else?
		Functionality (1=Poor, 10=Excellent, Don't Know)				21	Primary Resource	Primary Resource (1=Very Unlikely, 10=Very Likely)
4	Functionality - Usefulness	Please rate the usefulness of the services provided on this site.						How likely are you to use this site as your primary resource for getting information on Medicare?
5	Functionality - Convenient Services	Please rate the convenience of the services on this site.
6	Functionality - Accomplish Goal	Please rate the ability to accomplish what you wanted to on this site.
		Look and Feel (1=Poor, 10=Excellent, Don't Know)
8	Look and Feel - Readability	Please rate the ease of reading this site.
9	Look and Feel - Organization	Please rate the clarity of site organization.
10	Look and Feel - Layout	Please rate the clean layout of this site.
		Navigation (1=Poor, 10=Excellent, Don't Know)
11	Navigation - Clicks	Please rate the degree to which the number of steps it took to get where you want is acceptable.
12	Navigation - Find	Please rate the ability to find information you want on this site.
13	Navigation - Clarity of Map	Please rate the clarity of site map/directory.
14	Navigation - Ease of Navigation	Please rate the ease of navigation on this site.
		Site Performance (1=Poor, 10=Excellent, Don't Know)
15	Site Performance - Loading	Please rate the speed of loading the page on this site.
16	Site Performance - Consistency	Please rate the consistency of speed on this site.
17	Site Performance - Reliability	Please rate the reliability of site performance on this site.
		Search (1=Poor, 10=Excellent, Don't Know)
18	Search - Usefulness	Please rate the usefulness of search results on this site.
19	Search - Comprehensive Results	Please rate how this site provides comprehensive search results.
20	Search - Organization	Please rate the organization of search results on this site.
21	Search - Narrow	Please rate how the search feature helps you to narrow the results to find the information you want.

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Sheet 3: Current Custom Qsts

Model Instance Name:			red & strike-through: DELETE
CMS - CGS DME MAC B			underlined & italicized: RE-ORDER
			pink: ADDITION
Date:	6/9/2016		blue + -->: REWORDING
CMS - CGS DME MAC B CUSTOM QUESTION LIST
QID (Group ID)	Skip Logic Label	Question Text	Answer Choices (limited to 50 characters)	Skip to	Type (select from list)	Single or Multi	Required Y/N	Special Instructions	CQ Label
		Which best describes you?	Provider of medical services		Radio button, one-up vertical	Single	Y	OPS Group	Best describes you
			Supplier of medical equipment or supplies
			Staff of provider/supplier working primarily with billing/insurance
			Administrative staff of a provider/supplier
			Other staff of a provider/supplier
			Consultant or attorney
			Billing service
			Other (please specify)	A
	A	Other - which best describes you?			Text field, <100 char				Other_Best describes you
		What features did you use during your visit today: (Please select all that apply.)	MyCGS	R	Checkbox, one-up vertical	Multi	Y	Skip Logic Group	Features used
			ListServ	B
			Workshops / Seminars
			Online Education
			None
			Other (please specify)	A
	A	Please explain what other features you used during your visit.			Text area, no char limit			Skip Logic Group	OE_features
	R	What is your primary reason for visiting the myCGS Web Portal today:	Eligibility		Radio button, one-up vertical	Single	Yes	Skip Logic Group	Reason for portal
			Claim Status
			CMN Information
			Referring Physician
			Other (please specify)	S
	S	Other Reason for visiting portal			Text field, <100 char		No	Skip Logic Group	Other Reason for portal
	R	What enhancements would you like to see added to the myCGS Web Portal?			Text area, no char limit		No	Skip Logic Group	Portal enhancements
	R	How easy is accessing the information on the myCGS Web Portal?	Very Easy		Radio button, one-up vertical	Single	Yes	Skip Logic Group	Easy to access
			Easy
			Moderately Difficult
			Very Difficult
	R	How often do you use the myCGS Web Portal?	Daily		Radio button, one-up vertical	Single	Yes	Skip Logic Group	Portal use frequency
			A few times a week
			Once a week
			Monthly
			Rarely (less than monthly)
	B	Please rate your satisfaction with the frequency of communications you receive via the Listserv.	1 - too often		Radio button, scale, no don't know	Single	N	Skip Logic Group	Sat w listserv
			2
			3
			4
			5
			6
			7
			8
			9
			10 - not often enough
			Does not apply
		In the last 30 days, how many times have you visited this website?	This is my first time		Radio buttons	Single	Y	select one	Visit frequency
			Once or twice
			Three or four times
			More than once per week but not every day
			Every day
		What is your primary reason for visiting this site today?	Download forms		Radio buttons	Single	Y	select one	Reason for visiting
			Access claim status and/or beneficiary eligibility
			Learn of, or register for, workshops, seminars or other training events
			Find contact information
			Find general Medicare program information
			Research a specific question on Medicare policy or billing
			Find information on fees or fee schedules
			Find out about a Local Coverage Determination (LCD)
			Read Medicare publications such as newsletters, articles, etc.
			Find enrollment information
			Take an on-line training course
			Other (please specify)	Q
	Q	Other - primary reason?			Text field, <100 char				Other_Primary reason
		How did you primarily look for information on this site today?	Top navigation bar	N	Radio button, one-up vertical	Single	Y	OPS Group	Look for Info
			Left navigation bar	N
			Quick Links on the right side of the page	N
			Searched using the site search feature
			Used the site map	N
			Other (please specify)	O
	O	The other way I looked for information was:			Text area, no char limit		N	OPS Group	OE_Look for Info
	N	How would you describe your navigation experience on this site today? (Please select all that apply.)	I had no difficulty browsing on this site		Checkbox, one-up vertical	Multi	Y	Skip Logic Group	Navigation Experience
			Links often did not take me where I expected	E
			Links/labels are difficult to understand	F
			Too many links/navigational options to choose from
			Had technical difficulties (error messages, broken links, etc.)	E
			Could not navigate back to previous information
			Other navigation difficulty not listed above (please specify):	G
	E	What specific links did not take you where they should have?			Text area, no char limit	Single	N		Nav links wrong path
	F	What specific links/labels were difficult to understand?			Text area, no char limit	Single	N		Nav links/labels confusing
	G	The navigation difficulty I experienced was:			Text area, no char limit	Single	N		Other_Nav Experience
		Did you accomplish your goal in coming to the site today?	Yes		Radio button, one-up vertical	Single	Y	Skip Logic Group	Accomplish Goal
			No	C, D
	C	Please tell us what you were trying to do or find.			Text area, no char limit	Single	N	Skip Logic Group	Trying to Find
	D	What will you do next?	Nothing, although I did not find/complete what I wanted		Radio button, one-up vertical	Single	Y	Skip Logic Group	Do Next
			Call the CGS call center
			Return to the CGS website later and try again
			Send an email
			Try the CMS Website
			Write a letter
			Other (please specify)	A
	A	Please explain what you will you do next.			Text area, no char limit		N	Skip Logic Group	Other_Do Next
		If you could identify one improvement to the Web site, what would that improvement be?			Text area, no char limit		N		Open-improvement
		Which of the following sources drove you to visit the site today? Please rank the top 3 (Rank 1 is most important). Rank 1	Message or recommendation from a friend on a social network		Drop down, select one	Single	Y	Rank Group	SV - Rank 1
			Video I saw on YouTube
			Internet blogs or discussion forums					Adjust Template/Style Sheet
			Advertising on social networks (Facebook, My Space, Twitter)					Randomize
			Message directly from the company on a social network
			Mobile phone text messages or alerts
			Instant Message from a friend or colleague
			Familiarity with site or organization
			Promotional email(s) from the organization
			Search engine results
			Word of mouth recommendation from someone I know
			TV, radio, newspaper, or magazine advertising
			Internet advertising
			Don't know					Anchor Answer Choice
			Other					Anchor Answer Choice
		Rank 2 (Optional)	Message or recommendation from a friend on a social network		Drop down, select one	Single	N	Rank Group	SV - Rank 2
			Video I saw on YouTube
			Internet blogs or discussion forums					Adjust Template/Style Sheet
			Advertising on social networks (Facebook, My Space, Twitter)					Randomize
			Message directly from the company on a social network
			Mobile phone text messages or alerts
			Instant Message from a friend or colleague
			Familiarity with site or organization
			Promotional email(s) from the organization
			Search engine results
			Word of mouth recommendation from someone I know
			TV, radio, newspaper, or magazine advertising
			Internet advertising
			Don't know					Anchor Answer Choice
			Other					Anchor Answer Choice
		Rank 3 (Optional)	Message or recommendation from a friend on a social network		Drop down, select one	Single	N	Rank Group	SV - Rank 3
			Video I saw on YouTube
			Internet blogs or discussion forums					Adjust Template/Style Sheet
			Advertising on social networks (Facebook, My Space, Twitter)					Randomize
			Message directly from the company on a social network
			Mobile phone text messages or alerts
			Instant Message from a friend or colleague
			Familiarity with site or organization
			Promotional email(s) from the organization
			Search engine results
			Word of mouth recommendation from someone I know
			TV, radio, newspaper, or magazine advertising
			Internet advertising
			Don't know					Anchor Answer Choice
			Other					Anchor Answer Choice
		If you heard about this website from a social network, please specify the site (i.e. Facebook, Twitter)			Text area, no char limit		N		SV - Other Social Network
		If you are over the age of 18 and would like CGS to respond to your feedback regarding this website, please provide your email address here:			Text field with 100 character limit		N		Email