| Model Instance Name: |
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| CMS - Novitas JL MAC |
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| MID: |
Existing Measure - Please fill in; New Measure - DOT will fill in |
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| Date: |
5/20/2013 |
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| Welcome and Thank You Text |
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Directions: |
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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. |
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Examples |
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Welcome Text Example |
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Welcome Text |
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bharati.hulbanni:
if STORES MEASURE:
do NOT use any welcome text.
Thank you for visiting the Novitas Solutions, Inc. website. You have been randomly selected to take part in this brief website satisfaction survey. Please take a few minutes to share your opinions regarding our website elements, such as navigation, search, content, etc., which are essential in helping us provide the best online experience possible. Your comments and scores on this survey will be directed to the Medicare Internet Team. Therefore, please limit your comments and scores on this survey to your experiences and opinions on the Web Site only. |
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Thank You Text Example |
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DEFAULT Thank You Text |
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bharati.hulbanni:
TY text can be used for all measure types (call center, web, stores, mobile etc.)
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ALTERNATE WEB Thank You Text |
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bharati.hulbanni:
Use this TY text ONLY for WEB
Thank you for your time in completing this survey. Your input is very valuable and will be taken into consideration. |
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| Model Instance Name: |
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| CMS - Novitas JL MAC |
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| MID: |
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Existing Measure - Please fill in; New Measure - DOT will fill in |
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THIS IS THE CMS APPROVED SET OF MODEL QUESTIONS |
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| Partitioned (Y) |
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| FPI Included(N) |
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| 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. |
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THIS IS THE CMS APPROVED SET OF MODEL QUESTIONS |
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| Date: |
5/20/2013 |
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| CMS - Novitas JL MAC |
| Model questions utilize the ACSI methodology to determine scores and impacts |
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ELEMENTS (drivers of satisfaction) |
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CUSTOMER SATISFACTION |
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FUTURE BEHAVIORS |
FPI |
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MQ Label |
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MQ Label |
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MQ Label |
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Y? |
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Content (1=Poor, 10=Excellent, Don't Know) |
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Satisfaction |
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Primary Resource (1=Very Unlikely, 10=Very Likely) |
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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 |
Primary Resource |
How likely are you to use this site as your primary resource for getting information on Medicare? |
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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) |
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Recommend (1=Very Unlikely, 10=Very Likely) |
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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? |
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Functionality (1=Poor, 10=Excellent, Don't Know) |
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Return (1=Very Unlikely, 10=Very Likely) |
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| 4 |
Functionality - Usefulness |
Please rate the usefulness of the services provided on this site. |
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26 |
Return |
How likely are you to return to this site? |
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| 5 |
Functionality - Convenient Services |
Please rate the convenience of the services on this site. |
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| 6 |
Functionality - Accomplish Goal |
Please rate the ability to accomplish what you wanted to on this site. |
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Look and Feel (1=Poor, 10=Excellent, Don't Know) |
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| 7 |
Look and Feel - Readability |
Please rate the ease of reading this site. |
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| 8 |
Look and Feel - Organization |
Please rate the clarity of site organization. |
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| 9 |
Look and Feel - Layout |
Please rate the clean layout of this site. |
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Navigation (1=Poor, 10=Excellent, Don't Know) |
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| 10 |
Navigation - Steps |
Please rate the degree to which the number of steps it took to get where you want is acceptable. |
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| 11 |
Navigation - Find |
Please rate the ability to find information you want on this site. |
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| 12 |
Navigation - Layout |
Please rate the clarity of the site map/directory. |
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| 13 |
Navigation - Ease |
Please rate the ease of navigation on this site. |
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Search (1=Poor, 10=Excellent, Don't Know) |
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| 14 |
Search - Usefulness |
Please rate the usefulness of search results on this site. |
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| 15 |
Search - Comprehensive |
Please rate how this site provides comprehensive search results. |
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| 16 |
Search - Organization |
Please rate the organization of search results on this site. |
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| 17 |
Search - Narrow |
Please rate how the search feature helps you to narrow the results to find the information you want. |
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Site Performance (1=Poor, 10=Excellent, Don't Know) |
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| 18 |
Site Performance - Loading |
Please rate the speed of loading the page on this site. |
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| 19 |
Site Performance - Consistency |
Please rate the consistency of speed on this site. |
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| 20 |
Site Performance - Reliability |
Please rate the reliability of site performance on this site. |
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| Model Instance Name: |
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red & strike-through: DELETE |
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| CMS - Novitas JL MAC |
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underlined & italicized: RE-ORDER |
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| MID: Existing Measure - Please fill in; New Measure - DOT will fill in |
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pink: ADDITION |
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| Date: |
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5/20/2013 |
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blue + -->: REWORDING |
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| CMS - Novitas JL MAC CUSTOM QUESTION LIST |
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bharati.hulbanni:
Hide (DO NOT DELETE) this column before sending to a client.
QID |
FPI
Y? |
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 |
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In the last 30 days, how many times have you visited this website? |
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This is my first time |
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Radio button, one-up vertical |
Single |
Y |
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Visit Frequency |
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Once or twice |
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Three or four times |
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More than once per week but not every day |
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Every day |
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Which best describes you? |
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Provider of medical services |
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Radio button, one-up vertical |
Single |
Y |
Skip Logic Group* |
Best describes you |
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Supplier of medical equipment or supplies |
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Staff of provider/supplier working primarily with billing/insurance |
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Administrative staff of a provider/supplier |
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Other staff of a provider/supplier |
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Consultant or attorney |
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Billing service |
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Other |
A |
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A |
Please explain briefly: |
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Text area, no char limit |
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N |
Skip Logic Group* |
Other-Role |
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What is your primary reason for visiting this site today? |
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Download forms |
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Radio button, one-up vertical |
Single |
Y |
Skip Logic Group* |
Reason for visiting |
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Learn of, or register for, workshops, seminars or other training events |
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Find contact information |
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Find general Medicare program information |
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Research a specific question on Medicare policy or billing |
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Find information on fees or fee schedules |
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Find out about a Local Coverage Determination (LCD) |
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Read Medicare publications such as newsletters, articles etc. |
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Find enrollment information |
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Take an on-line training course |
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Other |
B |
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B |
Please explain briefly: |
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Text area, no char limit |
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N |
Skip Logic Group* |
Other-Primary Reason |
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What information center(s) or topic(s) did you access on our Web site today (check all that apply)? |
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Appeals |
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Checkbox, one-up vertical |
Multi |
Y |
OPS Group |
Info Centers or Topics Access |
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Audit and Reimbursement (Part A Fees) |
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CERT |
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Claims/Eligibility |
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Electronic Billing (EDI) |
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Enrollment |
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Evaluation and Management |
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Part B Fee Schedules |
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Forms Catalog |
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Medical Policy |
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Medicare News & Bulletins |
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Self-Service Tools |
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Provider Training and Events |
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I did not use an information center, but was looking for information on this topic: |
C |
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C |
Other information of interest: |
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Text area, no char limit |
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N |
OPS Group |
Other info of Interest |
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Did you use any search features on this site today? |
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Yes |
D, E, F |
Radio button, one-up vertical |
Single |
N |
Skip Logic Group* |
Search Feature Usage |
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No |
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D |
How would you rate the helpfulness of the search tool? |
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Very helpful |
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Radio button, one-up vertical |
Single |
N |
Skip Logic Group* |
Helpfulness of Search Tool |
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Somewhat helpful |
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Fair |
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Somewhat unhelpful |
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Very unhelpful |
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E |
What search term(s) did you use? |
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Text area, no char limit |
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N |
Skip Logic Group* |
Search Terms Used |
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F |
Please briefly explain your experience with the search tool. |
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Text area, no char limit |
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N |
Skip Logic Group* |
Search Tool Experience |
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How did you look for the information you wanted / needed on this site? (select all that apply) |
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Using the navigation menu on the left side of the page |
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Radio button, one-up vertical |
Single |
Y |
Skip Logic Group* |
Look for Information |
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Using links in the center of the page |
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Using the site search feature |
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Using the site map |
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Other |
G |
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G |
What other method did you use to look for the information you wanted / needed? |
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Text area, no char limit |
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N |
Skip Logic Group* |
Other Method to Look for Info |
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Were you able to accomplish your goal in visiting the Web site today? |
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Yes |
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Radio button, one-up vertical |
Single |
Y |
Skip Logic Group* |
Accomplish Goal |
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No |
H |
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H |
Please explain what you were unable to accomplish:. |
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Text area, no char limit |
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N |
Skip Logic Group* |
Unable to accomplish |
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How could the Web site be improved to make your job easier? |
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Text area, no char limit |
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N |
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One Improvement |
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Do you subscribe to Novitas' E-mail List (listserv)? |
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Yes |
I |
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N |
Skip Logic Group* |
Subscribe to E-mail list |
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No |
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I |
What enhancements could be made to our e-mail list to make it a more useful tool for you? |
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N |
Skip Logic Group* |
Email enhancements |
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If you are over the age of 18 and would like Novitas to respond to your feedback regarding this Web site, please provide your name, along with an e-mail address or telephone number here: |
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Text area, no char limit |
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N |
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Contact Information |
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Radio button, scale, has don't know |
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