419 CMS Palmetto G 419 CMS Palmetto GBA J11 MAC Questionnaire 3-10-11

Model Instance Name:
CMS Palmetto GBA J11 MAC
MID: xVtkhQ8Yh84FUFVxYcpsBg==
Date:	2/24/2011
CMS Palmetto GBA J11 MAC CUSTOM QUESTION LIST
CQID	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
SAC1415		Which best describes you?	Provider of medical services		Radio buttons	Single	Y	Skip Group	Best Describes You
			Supplier of medical equipment or supplies
			Staff of a 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	A
SAC1416	A	Please explain briefly your role in visiting this site.			Text area, no char limit	Single	N	Skip Group	OPS_Best Describes You
SAC1417		What is your primary reason for visiting this site today?	Download forms		Radio buttons	Single	Y	Skip Group	Visit Reason
			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
			Access claim status and/or beneficiary eligibility
			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	B
SAC1418	B	Please explain briefly your primary reason for visiting this site.			Text area, no char limit	Single	N	Skip Group	OPS_Visit Reason
SAC1419		Did you find what you were looking for?	Yes		Radio button, one-up vertical	Single	Y	Skip Group	Looking For
			No	C
SAC1420	C	No, I was looking for:			Text area, no char limit	Open	Y	Skip Group	Didn't Find
SAC1421		Did you use the site-wide search feature on this site? (open text box in the upper right)	Yes	D, E	Radio button, one-up vertical	Single	Y	Skip Group	Use Search
			No
SAC1422	D	How would you rate the helpfulness of the site-wide search?	Very helpful		Radio button, one-up vertical	Single	Y	Skip Group	Rate Search
			Somewhat helpful
			Fair
			Somewhat unhelpful	F
			Very unhelpful	F
SAC1423	F	Which of the following describes your experience with the site-wide search?	Search difficult to use		Radio button, one-up vertical	Single	Y	Skip Group	Search Experience
			Received too few results	G
			Received too many results
			Search results were not what I was looking for	H
			Could not sort or refine results
			Other	I
SAC1424	G	What search term(s) did you use?			Text area, no char limit	Single	N	Skip Group	Terms - Too Few
SAC1425	H	What search term(s) did you use?			Text area, no char limit	Single	N	Skip Group	Terms - Not What Look For
SAC1426	I	Please briefly explain your experience with the site-wide search.			Text area, no char limit	Single	N	Skip Group	Other_Search Experience
SAC1427	E	What one improvement to the site-wide search feature would be most beneficial?			Text area, no char limit	Single	N	Skip Group	Other-Search Improvement
SAC1428		In the last 30 days, how many times have you visited this website?	This is my first time		Radio buttons	Single	Y		Visit Frequency
			Once or twice
			Three or four times
			More than once per week but not every day
			Every day
SAC1429		Please rank the top 3 factors that brought you to the website today. (Rank 1 = 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					Adjust Template/Style Sheet
			Internet blogs or discussion forums					Randomize
			Advertising on social networks (Facebook, LinkedIn, Twitter)
			Message directly from Palmetto GBA on a social network
			Mobile phone text messages or alerts
			Instant Message from a friend or colleague
			Typed in the URL
			Bookmarked the website
			Search engine results
			Word of mouth recommendation from someone I know
			Link from the CMS website
			Listserv or email updates from Palmetto GBA
			Mobile apps
			None of the above					Anchor
			Don't know					Anchor
			Other					Anchor
SAC1430		Rank 2	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					Adjust Template/Style Sheet
			Internet blogs or discussion forums					Randomize
			Advertising on social networks (Facebook, LinkedIn, Twitter)
			Message directly from Palmetto GBA on a social network
			Mobile phone text messages or alerts
			Instant Message from a friend or colleague
			Typed in the URL
			Bookmarked the website
			Search engine results
			Word of mouth recommendation from someone I know
			Link from the CMS website
			Listserv or email updates from Palmetto GBA
			Mobile apps
			None of the above					Anchor
			Don't know					Anchor
			Other					Anchor
SAC1431		Rank 3	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					Adjust Template/Style Sheet
			Internet blogs or discussion forums					Randomize
			Advertising on social networks (Facebook, LinkedIn, Twitter)
			Message directly from Palmetto GBA on a social network
			Mobile phone text messages or alerts
			Instant Message from a friend or colleague
			Typed in the URL
			Bookmarked the website
			Search engine results
			Word of mouth recommendation from someone I know
			Link from the CMS website
			Listserv or email updates from Palmetto GBA
			Mobile apps
			None of the above					Anchor
			Don't know					Anchor
			Other					Anchor
SAC1432		If you heard about the website from a social network, please specify the site.	Facebook			Single	N	Skip Group	Heard About On Site
			LinkedIn
			YouTube
			Twitter
			Mobile apps
			Other, please specify	J
SAC1433	J	Please specify the other social network.			Text area, no char limit	Single	N	Skip Group	OPS_Heard About
SAC1434		Please select your location and contract: (please select all that apply)	South Carolina – Part A		Checkbox, one-up vertical	Multi	Y		Location
			South Carolina – Part B
			North Carolina – Part A
			North Carolina – Part B
			Virginia – Part A
			Virginia – Part B
			West Virginia – Part A
			West Virginia – Part B
			Not applicable
SAC1435		If you do not use E-mail Updates (listserv), please tell us why not.			Text area, no char limit	Open	N		Why Not Use Listserv
SAC1436		If you are over the age of 18 and would like to be contacted by Palmetto GBA regarding your feedback, please provide your e-mail address and/or phone number.			Text area, no char limit	Open	N		Contact Me
SAC1437		If you could change anything about our site, what would it be?			Text area, no char limit	Open	N		Change One Thing