Form CMS-10679 EMDI Workgroup Participation Survey

OMB control number: 0938-1185

Expiration date: 04/30/2019

Electronic Medical Document Interoperability (EMDI) Workgroup Participation Survey

Meeting Date*:		Time:
Workgroup Name*:
Submitter Name:		Organization:
Email:		Phone Number:

*Required Field

Questionnaire

Question	Answer
Workgroup goal was clearly identified.
Workgroup host identified the meeting purpose.
Workgroup followed the meeting agenda.
Workgroup was informative and relevant to the meeting topic.
Workgroup participants were actively engaged.
Workgroup addressed participants’ questions.
Workgroup allowed participants to provide comments and feedback.
Workgroup meeting schedule is convenient for your participation.
Workgroup next steps were properly identified.
My overall satisfaction with the workgroup is high. I would recommend this workgroup to other healthcare organizations.

Additional Comments:

Suggestions for future agenda topics:

Please submit the survey to [email protected].

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 0938-1185 (Expires 04/30/2019).  The time required to complete this information collection is estimated to average 20 minutes, 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 [email protected]

Electronic Medical Document Interoperability (EMDI)

Workgroup Participation Survey  2

This information is proprietary and confidential to Scope Infotech, Inc.