Form 626 2013 626 CMS NGS J6 MAC initial survey

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Overview

Guidelines
Welcome and Thank You Text
MODEL Questionst
Custom Questions

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Sheet 1: Guidelines

Questionnaire Management Guidelines

Goals:

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One consolidated document to track all model and CQ changes throughout the life of the project

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Questionnaire always matches the live survey

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Easy and error-free way to submit CQ changes

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All changes tracked and reflected in one document (DOT will help)

Questionnaire Resources:

1

Questionnaire Design and Approval Process

2

Question Grouping Rules

3

OPS vs. Skip Logic Decision for "Other, Please Specify"

4

Foreign Language Survey Instructions

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Sheet 2: Welcome and Thank You Text

Model Instance Name:
CMS - NGS J6 MAC
MID:	New Measure - DOT will fill in
Date:	5/20/2013
Welcome and Thank You Text
	Directions:
	This welcome text is shown at the top of the questionnaire window and the thank you text at the bottom. This is a good place to mention the site/company/agency name so the visitor knows whom they are taking the survey for. Feel free to modify the standard Welcome and Thank you text shown in the boxes below. Please read comments before using any of the text.
					Examples
					Welcome Text Example
	Welcome Text
	Thank you for visiting National Government Services. You have been randomly selected to take part in this survey that is being conducted by ForeSee on behalf of National Government Services. Please take a minute or two to give us your opinions. The feedback you provide will help National Government Services enhance its site and serve you better in the future. All results are strictly confidential.
				Thank You Text Example
	DEFAULT Thank You Text
	bharati.hulbanni: TY text can be used for all measure types (call center, web, stores, mobile etc.)
	ALTERNATE WEB Thank You Text
	bharati.hulbanni: Use this TY text ONLY for WEB Thank you for your time in completing this survey. Your input is very valuable to us and we will take it into consideration.

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Sheet 3: MODEL Questionst

Model Instance Name:
CMS - NGS J6 MAC
MID:		New Measure - DOT will fill in
Partitioned (Y)					THIS is the CMS Required Set of Model Questions
FPI Included (N)					THIS is the CMS Required Set of Model Questions
NOTE: All non-partitioned surveys will NOT be imputed and the elements will be rotated as a default unless otherwise specified and approved by Research.					THIS is the CMS Required Set of Model Questions
Date:	5/20/2013				THIS is the CMS Required Set of Model Questions
CMS - NGS J6 MAC
Model questions utilize the ACSI methodology to determine scores and impacts
		ELEMENTS (drivers of satisfaction)			CUSTOMER SATISFACTION			FUTURE BEHAVIORS	FPI
	MQ Label			MQ Label			MQ Label		N
		Content (1=Poor, 10=Excellent, Don't Know)			Satisfaction			Return (1=Very Unlikely, 10=Very Likely)
1	Content - Accuracy	Please rate the accuracy of information on this site.	21	Satisfaction - Overall	What is your overall satisfaction with this site? (1=Very Dissatisfied, 10=Very Satisfied)	24	Return	How likely are you to return to this site?
2	Content - Quality	Please rate the quality of information on this site.	22	Satisfaction - Expectations	How well does this site meet your expectations? (1=Falls Short, 10=Exceeds)			Recommend (1=Very Unlikely, 10=Very Likely)
3	Content - Freshness	Please rate the freshness of content on this site.	23	Satisfaction - Ideal	How does this site compare to your idea of an ideal website? (1=Not Very Close, 10=Very Close)	25	Recommend	How likely are you to recommend this site to someone else?
		Functionality (1=Poor, 10=Excellent, Don't Know)						Primary Resource (1=Very Unlikely, 10=Very Likely)
4	Functionality - Usefulness	Please rate the usefulness of the services provided on this site.				26	Primary Resource	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)
7	Look and Feel - Readability	Please rate the ease of reading this site.
8	Look and Feel - Organization	Please rate the clarity of site organization.
9	Look and Feel - Layout	Please rate the clean layout of this site.
		Navigation (1=Poor, 10=Excellent, Don't Know)
10	Navigation - Steps	Please rate the degree to which the number of steps it took to get where you want is acceptable.
11	Navigation - Find	Please rate the ability to find information you want on this site.
12	Navigation - Layout	Please rate the clarity of the site map/directory.
13	Navigation - Ease	Please rate the ease of navigation on this site.
		Search (1=Poor, 10=Excellent, Don't Know)
14	Search - Usefulness	Please rate the usefulness of search results on this site.
15	Search - Comprehensive	Please rate how this site provides comprehensive search results.
16	Search - Organization	Please rate the organization of search results on this site.
17	Search - Narrow	Please rate how the search feature helps you to narrow the results to find the information you want.
		Site Performance (1=Poor, 10=Excellent, Don't Know)
18	Site Performance - Loading	Please rate the speed of loading the page on this site.
19	Site Performance - Consistency	Please rate the consistency of speed on this site.
20	Site Performance - Reliability	Please rate the reliability of site performance on this site.

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Sheet 4: Custom Questions

Model Instance Name:

red & strike-through: DELETE

CMS - NGS J6 MAC

underlined & italicized: RE-ORDER

MID: New Measure - DOT will fill in

pink: ADDITION

Date:

4/26/2013

blue + -->: REWORDING

CMS - NGS J6 MAC CUSTOM QUESTION LIST

bharati.hulbanni: Hide (DO NOT DELETE) this column before sending to a client. QID

FPI Y? NO

bharati.hulbanni: there should be NO MORE THAN ONE LETTER IN HERE (Skip Logic Label) Skip Logic Label

Question Text

bharati.hulbanni: Hide (DO NOT DELETE) this column before sending to a client. AnswerIDs (DOT)

Answer Choices (limited to 50 characters)

Skip to

Type (select from list)

Single or Multi

Required Y/N

bharati.hulbanni: Can not have more than one CQ GroupType (denoted by an *) within one colored group in 'Special Instructions' . 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)

SKIP A

SKIP A

Other - which best describes you?

Text field, <100 char

N

OPS Group*

Other Role

In the last 30 days, how many times have you visited this website?

This is my first time

Radio button, one-up vertical

Single

Y

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 button, one-up vertical

Single

Y

Skip Logic Group*

Visit Reason

Learn of, or register for, workshops, seminars or other training events

Find contact information

Find general Medicare program information

Access claim status and/or beneficiary eligibility

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

B

B

Please specify your other reason for visiting this site today.

Text area, no char limit

N

Skip Logic Group*

Other Reason

What method are you primarily using to locate information on this site today?

Top navigation menu

Radio button, one-up vertical

Single

Y

Method using to get info

Links in the middle of the page

Search box

Site map

Other

Did you use the search feature on this site?

Yes

H

Radio button, one-up vertical

Single

Y

Skip Logic Group*

Use Search

No

H

Please describe your experience with the search feature. (Choose the best response)

I had no difficulty using the search feature on this site

Radio button, one-up vertical

Single

Y

Skip Logic Group*

Search Experience

The search feature was difficult to find

The search feature was difficult to use

Returned no results/received an error message

Could not tell where the search results would take me

Too many results

Too few results

Results were not related to what I was looking for

Could not sort the results

Could not refine the results

Other

H

What Keywords did you use?

Text area, no char limit

Single

N

Skip Logic Group*

Keywords

H

Please indicate how helpful you feel the search feature was in finding the information you were looking for.

Very helpful

Radio button, one-up vertical

Y

Search How Helpful

Somewhat helpful

I

Not at all helpful

I, J

J

Why do you feel the search feature was not at all helpful?

Text area, no char limit

Single

N

Skip Logic Group*

Search Not Helpful

I

What would make the search feature more helpful?

Text area, no char limit

Single

N

Skip Logic Group*

Make Search Helpful

While visiting the site, did you find what you were looking for?

Yes

Radio button, one-up vertical

Single

Y

Skip Logic Group*

Find

No

SKIP E, F

Not yet

SKIP E, F

SKIP E

What were you trying to locate? (Please be specific)

Text area, no char limit

N

Skip Logic Group*

Trying to Locate

SKIP F

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 NGS Contact Center

Return to the NGS website later and try again

Try the CMS website

Try another contractor's website

Send an email

Write a letter

Other (please specify)

SKIP G

SKIP G

Other (please specify)

Text area, no char limit

N

Skip Logic Group*

Other Do Next

If you could identify one improvement to this site, what would that improvement be?

Text area, no char limit

N

What Improvement

From time to time, National Government Services likes to reach out to website visitors to learn more about their experiences using the website. If you are over the age of 18 and would be willing to be contacted in the future, please provide your email address.

Text area, no char limit

N

Email Address