Form CMS-R-268 MSIInteractive Survey tool for www.,edicare.gov

CMS.gov/Medicare.gov Wave Survey – Updated 12/03/10
Thank you for visiting the CMS.gov or Medicare.gov website
The Centers for Medicare & Medicaid Services (CMS), the Federal agency that administers the
Medicare program is conducting this online survey to help us improve our websites and make
them more effective in getting you the information you need about your Medicare benefits and
your medical care.
Please take a few minutes to answer some questions that will help us to better meet your needs.
CMS will keep your information confidential, and the information is protected by the Privacy
Act.
You do not have to participate in this survey. Your help is voluntary and your decision to
participate or not to participate will not affect your Medicare benefits in any way. This is a
legitimate research study sponsored by the Centers for Medicare & Medicaid Services (CMS),
which is part of the United States Department of Health & Human Services.
According to the Paperwork Reduction Act of 1995, you do not have to respond to a U.S.
Government survey if it doesn’t display a valid OMB control number. The valid OMB control
number for this survey is 0938-0756. We estimate it will take less than 10 minutes to complete
this survey. This includes the time you’ll need to read instructions, look through online sources
of information, gather information that’s needed, review your answers, and submit the completed
survey. If you have comments about the accuracy of this time estimate or suggestions on how
we could improve this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Note: If you are currently in the middle of searching for information please minimize this
window until you’ve finished your search.
If you have already completed this survey, please close this window.
Top of Form
Bottom of Form

Question 1. How often do you visit the Medicare website or CMS website?
(Please select one answer.)
1
2
3
4
5
6
7

This is my first time
Less than once a month
1 to 3 times a month
About once a week
A few times a week
Once a day
A few times a day

{If Question 1 = Answers 2-7, ask Question 2 and Question 8d. Otherwise go to Introduction
before Question 17b.}
Question 2. How long have you been using the Medicare website or CMS website?
(Please select one answer.)
1 Less than one 1 month
2 1 to 6 months
3 6 to 11 months
4 1 or more years.

Question 17b. Which best describes you?
(Please select one answer.)
1
2

A Medicare recipient (currently or in the near future)
A relative or friend of a Medicare recipient (currently or in the
near future)
3 Social worker or health provider (such as physician, nurse, or
physician’s staff)
4 Employee of a health insurer, HMO, or managed care organization
5 Researcher, librarian, student, health benefits counselor, employer,
attorney
6 A member of an advocacy group representing people with
Medicare
7 A Medicare Customer Service Representative (CSR)
8 Another member of the Medicare staff
9 A member of a Quality Improvement Organization (QIO)
10 Other (Specify)
{If Question 17b = Answer 7, thank and terminate. If Question 1 = Answer 1, continue onto
Question 17c. Otherwise, continue to Question 3.}

Question 3. Why did you visit this website today?
(Please select all answers that apply.)
1
2
3
4
5
6
7
8
9
10

To find general information about Medicare and what Medicare covers
To find information on Medicare eligibility and enrollment
To find information on nursing homes or home health agencies
To find information on how to replace a lost or stolen Medicare card
To find information on supplemental health insurance (Medigap policies)
To find information about physicians in your area
To find information about prescription drug coverage
To compare Medicare health plans
Following a link from another website
Other (Specify)

{If Question 3 = Answer 9, ask Question 3a. Otherwise go to Introduction to Question 5a.}

Question 3a. What website were you at when you clicked the link that brought you to the
Medicare website or CMS website?

Programmer note: Question 4 was deleted, but historical numbering is retained.

Please tell us about your Overall Experience at the Medicare website or CMS website, by
entering how much you agree with each statement.
(Please read each statement and provide an answer on that line. If you are not sure about an
item, please enter "Don’t know".)
{Grid Question 5a – Question 5c.}

Question 5a. Overall, I had a good experience using this website.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 5b. Overall, this website met my expectations.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 5c. This website is as good as similar websites that I have visited.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Tell us how likely you are to come back to this website or to recommend it to a friend (by
entering how much you agree with each statement).
(Please read each statement and provide an answer on that line. If you are not sure about an
item, please enter "Don’t know".)
{Grid Question 6a – Question 5d.}

Question 6a. I will return to this website.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 6b. I will visit this website whenever I need to find health-related information.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 6c. I will recommend this website to a friend.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 6d. I will add this website to my bookmarks or favorite places.
[Record number 0-11]
0
10
11
12

Very much disagree
Very much agree
Don’t know
Already have

Please rate the overall content or material on the website.
(Please read each statement and provide an answer on that line. If you are not sure about an
item, please enter "Don’t know".)
{Grid and randomize Question 7a – Question 7f.}

Question 7a. The information is up to date.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 7b. I understand the information that I find here.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 7c. I trust the information I find here.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 7d. The information has the amount of detail that I need.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 7e. The information covers the topics I expect.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 7f. The information is useful.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Please rate the performance of this website by entering how much you agree or disagree with
these statements.
(Please read each statement and provide an answer on that line. If you are not sure about an
item, please enter "Don’t know". If you did not use a feature, enter “Not applicable”)
{Grid and randomize Question 8a – Question 8d.}

Question 8a. Pages were displayed (or loaded) quickly.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 8b. When I searched for something, I got results quickly.
[Record number 0-12]
0
10
11
12

Very much disagree
Very much agree
Don’t know
Not Applicable

Question 8c. When I clicked a link, it took me to the right place.
[RECORD NUMBER 0-12]
0
10
11
12

Very much disagree
Very much agree
Don’t know
Not Applicable

Question 8d. The website is always available when I visit.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Please tell us about your ability to interact with this website.
(Please read each statement and provide an answer on that line. If you are not sure about an
item, please enter "Don’t know".)
{Grid and randomize Question 9a – Question 9f.}

Question 9a. The links to information on this website and on other websites were helpful.
[Record number 0-12]
0
10
11
12

Very much disagree
Very much agree
Don’t know
Not Applicable

Question 9b. It was easy to subscribe to the mailing lists.
[Record number 0-12]
0
10
11
12

Very much disagree
Very much agree
Don’t know
Not Applicable

Question 9c. It was easy to order or download publications.
[Record number 0-12]
0
10
11
12

Very much disagree
Very much agree
Don’t know
Not Applicable

Question 9d. It was easy for me to give suggestions or make comments about the site.
[Record number 0-12]
0
10
11
12

Very much disagree
Very much agree
Don’t know
Not Applicable

Question 9e. It was easy to use the tools that let me find information about plans and facilities
(for example, Medicare Plan Finder, and Healthcare Provider Directory.)
[Record number 0-12]
0
10
11
12

Very much disagree
Very much agree
Don’t know
Not Applicable

Question 9f. It was easy to use the tools for comparing plans and facilities (For example,
Hospital Compare, and Nursing Home Compare.)
[RECORD NUMBER 0-12]
0
10
11
12

Very much disagree
Very much agree
Don’t know
Not Applicable

Please tell us what you think of the appearance of this website.
(Please read each statement and provide an answer on that line. If you are unfamiliar with that
item, please enter "Don’t know".)
{Grid and randomize Question 10a – Question 10e.)

Question 10a. The pages would be better if they had more color.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 10b. The color and size of the text makes it easy for me to read it.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 10c. The information is organized in a way that makes sense to me.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 10d. Overall, the pages on the website look good.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 10e. The pages would look better if they had more graphics.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

How would you rate getting around the website?
(Please read each statement and provide an answer on that line. If you are not sure about an
item, please enter "Don’t know". If you did not use a feature, enter “Not applicable”.)
{Grid and randomize Question 11a – Question 11d.}

Question 11a. The information I was looking for was easy to find.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 11b. The Search feature gave me links to pages or information I needed.
[Record number 0-12]
0
10
11
12

Very much disagree
Very much agree
Don’t know
Not Applicable

Question 11c. The information was clearly presented.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 11d. The links included enough information so that I knew which ones to click.
[Record number 0-12]
0
10
11
12

Very much disagree
Very much agree
Don’t know
Not Applicable

Please rate your comfort level with the website’s privacy and security.
(Please read each statement and provide an answer on that line. If you are unfamiliar with that
item, please enter "Don’t know".)
{Grid and randomize Question 12a – Question 12d.}

Question 12a. I believe they honor their privacy policy all the time.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 12b. They explain their privacy policy clearly.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 12c. They don’t ask for too much personal information.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 12d. The information they collect about me is only used for the specific purposes that
I requested.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 13. Have you looked at the tools available on the website that enable you to compare
plans, health care providers, or hospitals, etc.?

1
2
3
4
5

Yes, during today’s visit
Yes, within the past month
Yes, but more than one month ago
No
Don’t know

{If Question 13 = Answers 1-3, ask Introduction to Question 14. Otherwise go to Question 17a.}

How would you rate the tools that allow you to compare plans, health care providers, or
hospitals, etc.?
(Please read each statement and provide an answer on that line. If you are unfamiliar with that
item, please enter "Don’t know". If you did not use a feature, enter “Not applicable”)
{Grid and randomize Question 14a – Question 14e.}

Question 14a. The information I wanted was easy to find.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 14b. The information I got back was the information I was looking for.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 14c. The information was presented in a way that made it easy to follow.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 14d. The information was written in a way that was easy to understand.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 14e. I used or will use the information I found.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 15. Did you use the Home Health Agency Compare Tool?
1 Yes
2 No
3 Don’t know
{If Question 15 = Answer 1, ask Introduction to Question 16a. Otherwise go to Question 17a.}

Please rate the Quality Measures for Home Health Agencies on the Home Health Compare tool.
(Please read each statement and provide an answer on that line. If you are unsure about an item,
please enter "Don’t know")
{Grid and randomize Question 16a – Question 16e.}

Question 16a. The information I wanted was easy to find.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 16b. The information was presented in a way that made it easy to follow.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 16c. The information I got back was the information I was looking for.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 16d. I used or will use the information I found.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 16e. The information was written in a way that was easy to understand.
[Record number 0-11]
0 Very much disagree
10 Very much agree
11 Don’t know

Question 17a. What other comments do you have that will help us improve our site?
(Please type your answer in the box below.)

The last few questions are used for classification purposes. Your individual responses are kept
private.
Question 17c. From where are you accessing this site?
(Please select one answer.)
1
2
3
4

Home (yours or another)
Office (yours or another)
Library
Senior Center or Community
Center
5 School
6 Medical facility (such as a
hospital, doctor’s office, or
clinic)
7 Other (Specify)

Question 18. How comfortable are you with using the Internet?
(Please select one answer.)
1
2
3
4

I am very comfortable using the Internet.
I am somewhat comfortable using the Internet.
I am somewhat uncomfortable using the Internet.
I am very uncomfortable using the Internet.

Question 19a. Which of the following equipment do you use to assist you while using the
Internet?
(Please select all answers that apply.)
1
2
3
4
5
6
7
8

Screen reader or screen reviewer software
Screen enlarger
Speech input device
On-screen keyboard
Keyboard filters
Alternative input device (eye-gaze device, sip-and-puff system, etc.)
Other (Specify)
None of these

Question 20. What is your age?
(Please select one answer.)
1
2
3
4
5
6
7
8
9

Under 18
18-34 years old
35-44 years old
45-54 years old
55-64 years old
65-74 years old
75-84 years old
85 years or older
Prefer not to say

Question 21. What is the highest level of education that you have completed?
(Please select one answer.)
1
2
3
4
5
6

Less than high school
High school diploma
Some college or trade school
College degree (Bachelor level)
Master’s or Doctorate studies or degree
Prefer not to say

Question 22. What is the annual income of your household?
(Please select one answer.)
1
2
3
4
5
6

Under $20,000
$20,000 to $39,999
$40,000 to $59,999
$60,000 to $79,999
Over $80,000
Prefer not to say

Question 23. What is your gender?
(Please select one answer.)
1 Male
2 Female
3 Prefer not to say
{If Question 1 = Answers 2-7, ask Question 23. Otherwise thank and terminate.}

Question 24. What is the primary language spoken in your home?
(Please select one answer.)
1
2
3
4

English
Spanish
Other (Specify)
Prefer not to say

Thank you for participating in this survey!
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