Form CMS-668B Post Clinical Laboratory Survey Questionnaire

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard
Baltimore, MD 21244 -1850

Dear Laboratory Director:
Attached is the Post Clinical Laboratory Survey Questionnaire (CMS-668B). The purpose for collecting the
customer satisfaction data on this questionnaire is to evaluate, on a nationwide basis, the laboratory’s satisfaction
with their recent Clinical Laboratory Improvement Amendments (CLIA) survey. The information and suggestions
you provide will be used to evaluate and improve the CLIA survey process.
Your response to this form is entirely voluntary. All information provided in response to the CMS-668B is
considered proprietary, will be kept confidential, and will not be used for compliance purposes. We will release
only aggregate information to our State Agencies. We welcome your comments.
The Post Clinical Laboratory Survey Questionnaire is one page and should take approximately 15 minutes to
complete. We would appreciate it if you would take a moment to complete the questionnaire and return it. Your
comments are important and valued. If you need additional information concerning this questionnaire, please call
(410) 786-3531 or write to the return address listed on the back page of the questionnaire.
INSTRUCTIONS FOR COMPLETING THE QUESTIONNAIRE:
1. If your laboratory received an onsite survey (i.e., a CLIA survey that is usually conducted by your
State Agency), then you should skip Section II.
2. If your laboratory received the Alternative Quality Assessment Survey (i.e., paper CLIA survey of
quality indicators), then please skip Section I.
3. After completing the questionnaire, please detach it from this cover letter, fold, seal, and return it to
the address printed on the back of the form. Please note that this questionnaire is a self-mailer, not
requiring a separate envelope, and that the postage for returning this form has been prepaid.
The authority for the solicitation of this information is section 353 of the Public Health Service Act.

Attachment

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved
OMB No.0938-0653

POST CLINICAL LABORATORY SURVEY QUESTIONNAIRE
Please provide your comments about the recent CLIA survey of your laboratory.
Your information and suggestions will be used to evaluate and improve the survey process.
State in which laboratory is located:
Total Annual Volume of Testing:
❏ 1 to 2,000 tests
❏ 2,001 to 25,000 tests
❏ 100,001 to 1,000,000 tests
❏ Greater than 1,000,000 tests

❏ 25,001 to 100,000 tests

Type of Laboratory:
❏ Physician Office
❏ Home Health Agency

❏ Skilled Nursing Facility/Nursing Facility
❏ Other

❏ Hospital
❏ Independent

Did your laboratory receive the Alternate Quality Assessment Survey (paper survey)?
YES ❏
IF NO, GO TO SECTION I. IF YES, START AT SECTION II.
SECTION I - ONSITE SURVEY
Please give your overall impression of the survey. Using a scale from 1 to 5, circle the number that applies.
3. Neutral
5. Strongly Agree
1. Strongly Disagree
a.
b.
c.
d.
e.
f.
g.

NO ❏

The survey process was explained clearly.
1
2
3
4
The survey did not interfere with the delivery of care.
1
2
3
4
The survey assisted in your understanding of the CLIA requirements.
1
2
3
4
Deficiencies, if any, were explained clearly so that you understood what the problem was and why.
1
2
3
4
If deficiencies were found, the time frame and process for the plan of correction was explained.
1
2
3
4
The survey was completed in a reasonable amount of time.
1
2
3
4
The survey met your laboratory’s expectations.
1
2
3
4
AFTER COMPLETING THIS SECTION, SKIP SECTION II, AND GO TO SECTION III AND IV.

5
5
5
5
5
5
5

N/A
N/A

SECTION II - ALTERNATE QUALITY ASSESSMENT SURVEY (AQAS)
Please give your overall impression of the survey. Using a scale from 1 to 5, circle the number that applies.
1. Strongly Disagree
3. Neutral
5. Strongly Agree
a.
b.
c.
d.
e.
f.
g.

The questions on the AQAS were clear and understandable.
The form was not excessively lengthy.
Your facility made some changes in policies or procedures based on information in the form.
Your facility was able to complete and return the AQAS within 15 days of receipt.
If clarification was needed, you were able to contact the State Agency and receive assistance.
Your facility would have preferred an onsite survey instead of the AQAS for this survey cycle.
The AQAS is an efficient, effective replacement for an onsite survey.

1
1
1
1
1
1
1

2
2
2
2
2
2
2

3
3
3
3
3
3
3

4
4
4
4
4
4
4

5
5
5
5
5
5
5

N/A

SECTION III - GENERAL INFORMATION
a) Please recommend the one single change that would improve your facility’s survey experience.
b) Comments regarding the CLIA survey process in general:
SECTION IV - OPTIONAL INFORMATION

Facility Name

CLIA #

Date of Survey

After completing this questionnaire, please detach it from the cover letter, fold, seal and return it within 2 weeks to the address printed on
the back of this form. The preprinted address is:
Post Clinical Laboratory Survey Questionnaire Response
P.O. Box 8093
Baltimore, Maryland 21244-9942
THANK YOU FOR TAKING THE TIME TO ANSWER THESE QUESTIONS.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is 0938-0653. The time required to complete this information collection is estimated to
average 15 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
Form CMS-668B (01/12)

INSTRUCTIONS FOR MAILING:
1. Detach the form from the cover letter at the perforation.
2. Fold the top panel down at the horizontal line.
3. Moisten the very bottom of the opposite side of this panel.
4. Fold this panel up by sealing the top.