Form CMS-10415 CMS.gov User Satisfaction Survey

CMS.gov Survey

1. Are you a:

   1. [radio button] Health care provider (e.g., physician, nurse, physician assistant)

   2. [radio button] Health care facility (e.g., hospital, nursing home, home health agency, dialysis facility)

   3. [radio button] Health insurer or health plan

   4. [radio button] Researcher

   5. [radio button] Policymaker or policy analyst 

   6. [radio button] Government employee (Federal)

   7. [radio button] Government employee (State)

   8. [radio button] CMS partner organization (e.g., advocate, professional organizations)

   9. [radio button] Other - {freeform text}

2. Do you find the www.cms.gov website:

   1. [radio button] Very useful

   2. [radio button] Somewhat useful

   3. [radio button] Not useful

3. Were you able to find the information you were looking for today?

   1. [radio button] Yes

   2. [radio button] No

4. [Conditional if “Yes” to #3] What was the topic?

   1. [freeform text]

5. [Conditional if “No” to #3] What was the topic?

   1. [freeform text]

6. What’s the most useful part of the www.cms.gov website?

   1. [text response]

7. What’s the least useful part of the www.cms.gov website?

   1. [text response]

8. Are there specific changes you’d recommend to www.cms.gov?

   1. [radio button] Yes

      1. [freeform text]

   2. [radio button] No

9. Are there other websites that you recommend we evaluate for ideas on how to improve www.cms.gov?

   1. [radio button] Yes

      1. [freeform text]

   2. [radio button] No

PRA Disclosure Statement

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-XXXX.  The expiration date is (XX/XX/XXXX). The time required to complete this information collection is estimated to average [Insert Time (hours or 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. ****CMS Disclosure****  Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact [List Program Specific Contact].