Form CMS-10598 Stakeholder Survey

Stakeholder Training Evaluation Form

Webinars, Webinar-based Q&A Sessions, and User Groups

Instructions:

The following instructions will appear on all surveys.

Please take a moment to answer the following questions regarding the Stakeholder Training <Webinar/Q&A Session/User Group>, <Complete Title of Session (including series name, if applicable)> held on <mm/dd/yyyy>. Your feedback will assist CMS in determining the extent to which we achieved the goals of the training and will help CMS to make improvements for future training sessions. Your responses will remain confidential and will be reported in aggregate form only. Please do not include in your responses any personally identifiable information (PII).

Section A: Session Logistics

The following questions will appear in Section A for Webinars and Webinar-based Question & Answer (Q&A) Sessions.

1. Please rate your level of satisfaction with each of the following logistical aspects of the webinar. Select one response for each aspect.

Aspect	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied	Not Applicable
Ease of the webinar log-in process	¢	¢	¢	¢	¢
Webinar functionality	¢	¢	¢	¢	¢
Audibility of the speaker(s)	¢	¢	¢	¢	¢
Question and Answer (Q&A) process	¢	¢	¢	¢	¢

The following questions will appear in Section A for User Groups.

1. Please rate your level of satisfaction with each of the following logistical aspects of the User Group. Select one response for each aspect.

Aspect	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied	Not Applicable
Ease of audio access	¢	¢	¢	¢	¢
Audibility of the speaker(s)	¢	¢	¢	¢	¢
Question and Answer (Q&A) process	¢	¢	¢	¢	¢

OMB Control No.: 0938-NEW

Expiration Date: XX/XX/XXXX

Section B: Session Facilitation and Content

The following questions will appear in Section B for all sessions.

1. Please rate your level of satisfaction with the facilitation of the <Webinar/ Q&A Session/User Group>.

   1. Very satisfied

   2. Satisfied

   3. Dissatisfied

   4. Very Dissatisfied

2. Please indicate your level of agreement with each the following statements regarding the current session. Select one response per statement.

Statement	Strongly Agree	Agree	Disagree	Strongly Disagree	Not Sure	Not Applicable
As a result of this session, I clearly understand the concept of <pre-specified topic>.	¢	¢	¢	¢	¢	¢
In general, the session met the stated learning objectives	¢	¢	¢	¢	¢	¢
The information provided during this session will be useful to my organization	¢	¢	¢	¢	¢	¢

3. <FINAL SESSION OF THE MONTH ONLY> To what extent have you utilized the information provided during the <Title of Series>, during the month of [Month Year]?

1. To a great extent

2. To a moderate extent

3. To little extent

4. Not at all

4. <FINAL SESSION OF THE MONTH ONLY> To what extent has the information provided during the <Title of Series>, during the month of [Month Year] helped you in your role?

a. To a great extent

b. To a moderate extent

c. To little extent

d. Not at all

Section C: Overall Satisfaction

The following question will appear in Section C for all sessions.

1. Please rate your level of overall satisfaction with this <Webinar/Q&A Session/User Group> session.

1. Very satisfied

2. Satisfied

3. Dissatisfied

4. Very Dissatisfied

The following question will appear in Section C for the final session of the month for Webinar, Webinar Q&A or User Group sessions.

2. Please rate your general level of satisfaction with the <Title of Series> sessions held during the month of <Month/Year>.

1. Very satisfied

2. Satisfied

3. Dissatisfied

4. Very Dissatisfied

5. Don’t Know/Not Applicable

Section D: Comments and Suggestions

The following questions will appear in Section D for all sessions.

1. (PROGRAMMER INSTRUCTION: IF DISSATISFIED OR VERY DISSATISFIED WITH ANY ASPECT…) If you expressed dissatisfaction with at least one specific aspect of this session, in the space below, please provide a brief description of why you were dissatisfied.

Session Logistics:

Session Facilitation and Content:

2. What did you like most about this session?

3. What suggestions do you have for future <Title of Session/Title of Series> topics?

4. Do you have any additional comments regarding the <Title of Session> training session <FOR THE END OF THE SERIES ONLY> or the <Title of Series> series as whole <for a series>?

Section E: Background Information

The following questions in Section E will appear on all surveys.

1. Which of the following best describes your organization? (Select one category that best describes your organization.)

1. Agent/Broker/Web-Broker

2. Auditor/Potential Initial Validation Auditor (IVA)

3. Centers for Medicare & Medicaid Services (CMS)

4. Consultant/Contractor

5. Consumer Operated and Oriented Plans (CO-OPs)

6. Dental Plan

7. Federally-facilitated Marketplace (FFM) Issuer

8. Industry Association

9. Issuer Vendor

10. Navigators and Marketplace Assistor

11. Non-Marketplace Issuer

12. Pharmacy Benefit Managers (PBM)

13. Qualified Health Plan/Issuer

14. Regulator

15. State Agency

16. State-Based Marketplace (SBM) Issuer

17. State Reinsurance Entity

18. Third Party Administrator (TPA)

19. Other (Specify):

2. (PROGRAMMER INSTRUCTION: If E, F, G, K, M or P SELECTED ABOVE…)

Which of the following best describes your organization’s issuer status? (Select the category that best describes your status.)

1. New Issuer (1 year or less)

2. Existing Issuer (More than 1 year)

3. Not sure

3. Location of organization (State) (Select one category from dropdown list.)(PROGRAMMER INSTRUCTION: INSERT DROPDOWN LIST.)

4. Which of the following best describes your role within your organization? (Select one category that best describes your role.)

1. Chief Executive Officer

2. Chief Financial Officer

3. Compliance Staff

4. Agent

5. Broker

6. CMS Staff

7. CMS Contractor

8. Business/Program Analyst

9. Third Party Submitter

10. Finance/Revenue Staff

11. Coder/Data Analyst

12. Operations Staff

13. Risk Adjustment Staff

14. Program/Project Manager

15. Information Technology Staff

16. Consultant

17. Industry Association Representative

18. Quality Assurance/Quality Control Staff

19. Other (specify):

Thank you for completing the Stakeholder Training evaluation form.

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 0938-1185. 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 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.