Form CMS-10415 MyMedicare.gov Survey

Questions for eMSN & Plans and Coverage Pages  

Question Number	Potential Questions	Answer Choices	Display Logic
eMSN Questions:
eMSN - 1	Was the eMSN page useful?	Yes / No	Show for all users: If “Yes” display question 2 If “No” display question 1a
eMSN – 1a	Please provide suggestions on what could make the eMSN page more useful.	Open text field with a 500 character limit	Display this question if the answer to eMSN - 1 = “No”.
eMSN – 2	Have you signed up to receive MSNs electronically?	Yes / No	Show for all users: If “Yes” display question 2a If “No” display question 2b
eMSN – 2a	Were you able to easily download the PDFs?	Yes / No / I did not have any PDFs available for download	Display this question if the answer to eMSN - 2 = “No”.
eMSN – 2b	If you’re not signed up to receive eMSNs, was the instruction text helpful in describing how to sign up for eMSNs?	Yes / No	Display this question if: Answer to eMSN - 2 = “No”
eMSN – 3	Were you able to easily navigate through the eMSN page?	Yes / No	Show for all users: If “Yes” display question 4 If “No” display question 3a
eMSN – 3a	Please provide suggestions on what could make the eMSN page navigation easier to use.	Open text field with a 500 character limit	Display this question if the answer to eMSN - 3 =  “No”.
eMSN – 4	How visually appealing would you rate this page?	Very appealing / Somewhat appealing / Not very appealing	Show for all users.
eMSN - 5	If you could change one thing about this page, what would it be and why?	Open text field with a 500 character limit	Show for all users.
Plans & Coverage Questions:
Plans & Coverage – 1	What were you trying to accomplish on this page? - Print a temporary prescription drug card -  View prescription plans -  View insurance plans -  View plan details and drug costs -  View ‘other’ insurance information -  Something else	- Print a temporary prescription drug card -  View prescription plans -  View insurance plans -  View plan details and drug costs -  View ‘other’ insurance information -  Something else	Show for all users: If any of the non-“something else” choices display question 2 If “Something else” display question 1a
Plans & Coverage – 1a	Please describe what you were trying to accomplish on the Plans and Coverage page?	Open text field with a 500 character limit	Display this question if the answer to Plans & Coverage - 1 = “Something else”.
Plans & Coverage – 2	Was the Plans & Coverage page easy to use?	Yes / No	Show for all users: If “Yes” display question 3 If “No” display question 2a
Plans & Coverage – 2a	Please provide suggestions on what could make the Plans & Coverage page navigation easier to use.	Open text field with a 500 character limit	Show this question if the answer to Plans & Coverage - 2 =  “No”.
Plans & Coverage – 3	How visually appealing would you rate this page?	Very appealing / Somewhat appealing / Not very appealing	Show for all users.
Plans & Coverage - 4	If you could change one thing about this page, what would it be and why?	Open text field with a 500 character limit	Show for all users.

Note: the following text will be appended to all free form text fields, ‘Please do not include any personal health or login information in your responses.’

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].