Form CMS-10512 Survey on Core Competencies for the Direct Service Workf

TITLE: Survey on Core Competencies for the Direct Service Workforce

OMB CONTROL NUMBER: 0938-1229

This document contains screenshots of the online survey tool as it will appear to respondents. A dark blue bar reading “Survey on Core Competencies for the Direct Service Workforce” indicates the start of a new survey screen. The first two screens had to be captured as multiple images. The variations in font size will not occur. They are only in this document to allow screens to fit as one image here.

After respondents click “Done” they will see the following screen associated with the online survey program we are using (SurveyMonkey).