OMB # 0938-0919
CMS Beneficiary Satisfaction Survey [Master List]
Q.1 Good _________ (morning/afternoon/evening), my name is ________ and I am calling on behalf of Medicare about a call that was made from this number on {READ (day/date) FROM SAMPLE].
Are you the person in your household who contacted Medicare?
[IF YES:] SKIP TO QUESTION Q2.
[IF NO:] “Could you please put that person on the phone to answer our questions?”
If person answers “Yes”, repeat QUESTION Q1.
If person answers “No” or does not answer: “Thank you for your time, and enjoy the rest of your ___________ (morning/afternoon/evening).”
[IF PERSON NOT AVAILABLE:] ASK WHEN THEY CAN BE REACHED, SCHEDULE CALLBACK. “Thank you for your time.”
[IF MEDICAL PROVIDER ANSWERS:] “We were calling to speak with Medicare beneficiaries and did not realize that this was a provider phone number. Thank you for your time.”
[IF NO ONE IN HOUSEHOLD CALLED MEDICARE:] “This is all the information that I need today. Thank you for your time.”
q 1 Yes [SKIP TO QUESTION Q2]
q 2 No [READ RESPONSE ABOVE]
q 3 Medical provider answers [READ RESPONSE ABOVE]
q 4 Person not available [SCHEDULE CALLBACK]
q 5 No one in household called Medicare [READ RESPONSE ABOVE]
q 6 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.2 I would appreciate a few minutes of your time to answer some questions that will help improve Medicare services. Your participation is voluntary. This call may be monitored for quality and training purposes.
Were you calling for yourself, or on behalf of someone else?
q 1 Myself (yourself)
q 2 Someone else
q 7 [VOL] Don’t Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
[IF THE ANSWER IS “Myself (yourself)”, THEN SKIP TO Q.4]
________________________________________________________________________________________________________________________________________
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0919. The time required to complete this information collection is estimated to average 1.5 minutes per response, including the time the review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: Reports Clearance Officer, 7500 Security Boulevard, C5-14-03, Baltimore, Maryland 21244-1850
Q.3 What is your relationship to the Medicare beneficiary?
q 1 Daughter
q 2 Son
q 3 Sibling (Brother or Sister)
q 4 Spouse (Husband or Wife)
q 5 Niece or Nephew
q 6 Caregiver
q 7 Friend
q 8 Some other relationship
q 9 [VOL] Don't Know/Refused
q 10 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.4 Is this the first time you have ever contacted Medicare?
q 1 Yes
q 2 No
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.5 Were you able to reach a Customer Service Representative?
q 1 Yes
q 2 No
q 7 [VOL] Don't Know
q 8 [VOL] Refused
(If No/Don’t Know/Refused, skip to Q.13)
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.6 Was the first person that you spoke with able to answer all of your questions?
q 1 Yes
q 2 No
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.8 Using a scale of 1 to 5 where 1 is poor and 5 is excellent, please tell me how you would rate the time it took you to get through to a Customer Service Representative that helped you?
[PROMPT: USE A SCALE WHERE 1 IS POOR AND 5 IS EXCELLENT]
q 1 Poor
q 2 2
q 3 3
q 4 4
q 5 Excellent
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.9 Again on a scale of 1 to 5 where 1 is poor and 5 is excellent, please tell me how you would rate the person's knowledge of the Medicare system?
[PROMPT: USE A SCALE WHERE 1 IS POOR AND 5 IS EXCELLENT]
q 1 Poor
q 2 2
q 3 3
q 4 4
q 5 Excellent
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.10 Again on a scale of 1 to 5 where 1 is poor and 5 is excellent, How would you rate the politeness of the person on the phone?
[PROMPT: USE A SCALE WHERE 1 IS POOR AND 5 IS EXCELLENT]
q 1 Poor
q 2 2
q 3 3
q 4 4
q 5 Excellent
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.11 How would you rate the person’s ability to understand your question or concern?
[PROMPT: USE A SCALE WHERE 1 IS POOR AND 5 IS EXCELLENT]
q 1 Poor
q 2 2
q 3 3
q 4 4
q 5 Excellent
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.12 How would you rate the person’s ability to give you a clear answer to your questions?
[PROMPT: USE A SCALE WHERE 1 IS POOR AND 5 IS EXCELLENT]
q 1 Poor
q 2 2
q 3 3
q 4 4
q 5 Excellent
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.13 When you called the Customer Service Center, did you use the automated telephone system?
q 1 Yes
q 2 No
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
(If No/Don’t Know/Refused, skip to Q.26)
Q.14 Did you choose any of the following particular menu options?
[READ LIST]
[SELECT ALL THAT APPLY ALLOW FOR UP TO THREE RESPONSES]
q 1 Speak with CSR
q 2 Sign up for Medicare/Replace Medicare card/Change address
q 3 Medicaid
q 4 Claims information – Issues w/billing- hospital, doctor, equip
q 5 Medicare publication/HMO information
q 6 Frequently asked questions
q 7 Did not choose an option
q 8 Chose an option but cannot remember which
q 97 [VOL] Don’t know
q 98 [VOL] Refused
q 99 [VOL] No additional Selection
q 100 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.15 When you used the automated telephone system, did you receive all the information you needed from it?
q 1 Yes
q 2 No
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.16 Would you use the automated system again to get information about Medicare?
q 1 Yes
q 2 No
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.17 Thinking now about your general experience with using the automated telephone system, how would you rate the following on a scale of 1 to 5 where 1 is poor and 5 is excellent?
How would you rate the clarity of the instructions on the automated telephone system?
[PROMPT: USE A SCALE WHERE 1 IS POOR AND 5 IS EXCELLENT]
q 1 Poor
q 2 2
q 3 3
q 4 4
q 5 Excellent
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.18 How would you rate the ease of getting information from the automated telephone system?
[PROMPT: USE A SCALE WHERE 1 IS POOR AND 5 IS EXCELLENT]
q 1 Poor
q 2 2
q 3 3
q 4 4
q 5 Excellent
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.19 How would you rate the time it took for the automated telephone system to give you information?
[PROMPT: USE A SCALE WHERE 1 IS POOR AND 5 IS EXCELLENT]
q 1 Poor
q 2 2
q 3 3
q 4 4
q 5 Excellent
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.20 How would you rate the voice quality of the automated telephone system?
[PROMPT: USE A SCALE WHERE 1 IS POOR AND 5 IS EXCELLENT]
q 1 Poor
q 2 2
q 3 3
q 4 4
q 5 Excellent
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.21 Did you order a publication from the automated system or a Customer Service Representative, or off of the Medicare web site?
q 1 Yes
q 2 No
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
(If No/ Don’t Know/Refused, skip to Q.30)
Q.22 Have you received the publication(s) that you requested?
q 1 Yes/All
q 2 No/None
q 3 Some
q 7 [VOL] Don’t Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
* (If No/ Don’t Know/Refused, skip to Q.30)
** (If Some, a script prompt of “The next three questions pertain only to the publication(s) that you have received” will appear on the CSR’s screen).
Q.23 Did you receive the publication(s) within 3 weeks?
q 1 Yes/All
q 2 No/None
q 3 Some
q 7 [VOL] Don’t know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.24 Did you receive the correct publication(s)?
q 1 Yes/All
q 2 No/None
q 3 Some
q 7 [VOL] Don’t know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.25 Did the publication(s) arrive in good physical condition?
q 1 Yes/All
q 2 No/None
q 3 Some
q 7 [VOL] Don’t know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.26 From the time your call began to the time you hung up, how would you rate the time you spent on the call, where 1 is poor and 5 is excellent?
q 1 Poor
q 2 2
q 3 3
q 4 4
q 5 Excellent
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.27 How would you rate your overall experience with Medicare Customer Service ? Again, please use the scale where 1 is poor and 5 is excellent?
q 1 Poor
q 2 2
q 3 3
q 4 4
q 5 Excellent
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.28 Would you call the 1-800-MEDICARE Helpline number again?
q 1 Yes
q 2 No
q 7 [VOL] Don’t Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.29 Would you give the MEDICARE Helpline number to a friend?
q 1 Yes
q 2 No
q 7 [VOL] Don’t Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.30 Have you seen any recent television ads for 1-800-MEDICARE?
q 1 Yes
q 2 No
q 7 [VOL] Don’t Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
(If No/Don’t Know/Refused, skip to Q.33)
Q.31 Did you contact 1-800-MEDICARE as a result of seeing a television ad?
q 1 Yes
q 2 No
q 7 [VOL] Don’t Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.32 What was your impression of the ad(s) (favorable or unfavorable)?
q 1 favorable
q 2 unfavorable
q 7 [VOL] Don’t Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.33 Thinking about the Medicare telephone service that is provided to you, do you have any suggestions to make the service better?
q 1 Yes
q 2 No
q 7 [VOL] Don't Know
q 8 [VOL] Refused
q 9 [VOL] Hung up/Abandoned [TERMINATE SUVEY]
Q.34 In your own words, what are those suggestions? [PROBE FOR RESPONSE; RECORD RESPONSE VERBATIM]
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Q.35 Thank you very much for using Medicare services, and for taking the time to answer these questions. Your answers will help to continually improve Medicare service.
CMS
10098 Page
| File Type | application/msword |
| File Title | HCFA PA 1-800 Pilot Survey |
| Author | TKirby |
| Last Modified By | Lindsay Dixon |
| File Modified | 2007-08-02 |
| File Created | 2007-08-02 |