Form 30628 Q_CGSDMEB_Web_Browse_20180907_DOT
E-Government Website Customer Satisfaction Surveys
Q_CGSDMEB_Web_Browse_20180907_DOT.xlsx
Mapping and Questionnaire Documents IA 30628 A4 (CMS)
OMB: 1090-0008
⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1090-0008 can be found here:
Document [xlsx]
Download: xlsx | pdf
Updated Model
Current CQs
CQs (9-7-18)
CQs (1-4-17)
Overview
Welcome and Thank You TextUpdated Model
Current CQs
CQs (9-7-18)
CQs (1-4-17)
Sheet 1: Welcome and Thank You Text
| Model Instance Name: | 
|
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| CMS - CGS DME MAC B V2 | |||||||||||
| MID: | |||||||||||
| Date: | 12.1.16 | ||||||||||
| Welcome and Thank You Text | |||||||||||
| Directions: | |||||||||||
| This welcome text is shown at the top of the questionnaire window and the thank you text at the bottom. This is a good place to mention the site/company/agency name so the visitor knows whom they are taking the survey for. Feel free to modify the standard Welcome text shown in the box below. | |||||||||||
| Examples | |||||||||||
| Welcome Text Example | |||||||||||
|
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| Welcome Text | |||||||||||
| Customer Satisfaction Survey Thank you for visiting CGS. You have been randomly selected to take part in this survey that is being conducted by ForeSee Results on behalf of CGS. Please take a minute or two to give us your opinions. The feedback you provide will help CGS enhance its site and serve you better in the future. All results are strictly confidential. |
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| Thank You Text Example | |||||||||||
| Thank You Text | 
|
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| Thank you for your time in completing this survey. Your input is very valuable and will be taken into consideration. |
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Sheet 2: Updated Model
| Model Instance Name: CMS - CGS DME MAC B V2 | ||||||||
| Model Name | CMS - CGS DME MAC B V2 | |||||||
| Model ID | 140lwY4cIZNwMRBBopI1tw4C | |||||||
| Partitioned? Yes | 2MQ | |||||||
| Date: | 12.1.16 | |||||||
| CMS - CGS DME MAC B V2 | ||||||||
| Model questions utilize the ACSI methodology to determine scores and impacts | ||||||||
| ELEMENTS (drivers of satisfaction) | CUSTOMER SATISFACTION | FUTURE BEHAVIORS | ||||||
| MQ Label | MQ Label | MQ Label | ||||||
| Look and Feel (1=Poor, 10=Excellent, Don't Know) | Satisfaction | Primary Resource (1=Not Very Likely, 10=Very Likely) |
||||||
| 1 | Look and Feel - Appeal | Please rate the visual appeal of this site. | 21 | Satisfaction - Overall | What is your overall satisfaction with this site? (1=Very Dissatisfied, 10=Very Satisfied) |
24 | Primary Resource | How likely are you to use this site as your primary resource for getting information on Medicare? |
| 2 | Look and Feel - Balance | Please rate the balance of graphics and text on this site. | 22 | Satisfaction - Expectations | How well does this site meet your expectations? (1=Falls Short, 10=Exceeds) |
Recommend (1=Not Very Likely, 10=Very Likely) |
||
| 3 | Look and Feel - Legibility | Please rate the legibility of the pages on this site. | 23 | Satisfaction - Ideal | How does this site compare to your idea of an ideal site? (1=Not Very Close, 10=Very Close) |
25 | Recommend | How likely are you to recommend this site to someone else? |
| Site Performance (1=Poor, 10=Excellent, Don't Know) | Likelihood to Return (1=Not Very Likely, 10=Very Likely) |
|||||||
| 4 | Site Performance - Loading | Please rate how quickly pages load on this site. | 26 | Return | How likely are you to return to this site? | |||
| 5 | Site Performance - Consistency | Please rate the consistency of speed from page to page on this site. | ||||||
| 6 | Site Performance - Completeness | Please rate how completely the page content loads on this site. | ||||||
| Navigation (1=Poor, 10=Excellent, Don't Know) | ||||||||
| 7 | Navigation - Organized | Please rate how well this site is organized. | ||||||
| 8 | Navigation - Options | Please rate the options available for navigating this site. | 
|
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| 9 | Navigation - Layout | Please rate how well the site layout helps you find what you need. | ||||||
| Information Browsing (1=Poor, 10=Excellent, Don't Know) | ||||||||
| 10 | Information Browsing - Sort | Please rate the ability to sort information by criteria that are important to you on this site. | ||||||
| 11 | Information Browsing - Narrow | Please rate the ability to narrow choices to find the information you are looking for on this site. | ||||||
| 12 | Information Browsing - Features | Please rate how well the features on the site help you find the information you need. | ||||||
| 13 | Site Information (1=Poor, 10=Excellent, Don't Know) | |||||||
| Site Information - Thoroughness | Please rate the thoroughness of information provided on this site. | |||||||
| 14 | Site Information - Relevant | Please rate how relevant this site’s information is. | ||||||
| 15 | Site Information - Answers | Please rate how well the site’s information provides answers to your questions. | ||||||
Sheet 3: Current CQs
| Model Name | CMS - CGS DME MAC B V2 | ||||||||
| Model ID | 140lwY4cIZNwMRBBopI1tw4C | underlined & italicized: RE-ORDER | |||||||
| Partitioned | 2MQ | pink: ADDITION | |||||||
| Date | blue + -->: REWORDING | ||||||||
| CMS - CGS CME MAC B V2 CUSTOM QUESTION LIST | |||||||||
| QID (Group ID) |
Skip Logic Label | Question Text | Answer Choices (limited to 50 characters) |
Skip to | Type (select from list) | Single or Multi | Required Y/N |
Special Instructions | CQ Label |
| HDU7123Q001 | Which best describes you? | Supplier of medical equipment or supplies | Radio button, one-up vertical | Single | Y | Skip Logic Group | Best describes you | ||
| Staff of provider/supplier working primarily with billing/insurance | |||||||||
| Administrative staff of a provider/supplier | |||||||||
|
|
Provider of medical services | ||||||||
| Billing service | |||||||||
| Other staff of a provider/supplier | |||||||||
| Consultant or attorney | |||||||||
| Other (please specify) | A | ||||||||
| JIB0145997 | A | What best describes you? | Text area, no char limit | N | Skip Logic Group | OE_Role | |||
| HDU7123Q002 | In the last 30 days, how many times have you visited this website? | This is my first time | Radio button, one-up vertical | Single | Y | Visit frequency | |||
| Once or twice | |||||||||
| Three or four times | |||||||||
| More than once per week but not every day | |||||||||
| Every day | |||||||||
| HDU7123Q003 | Did you log in to the myCGS Web Portal today? | Yes | A | Radio button, one-up vertical | Y | Skip Logic Group | Log In | ||
| No | |||||||||
| HDU7123Q004 | A | What is your primary reason for logging in to the myCGS Web Portal today? | Eligibility | Radio button, one-up vertical | Single | Y | Skip Logic Group | Reason for portal | |
| Claim status | |||||||||
| CMN information | |||||||||
| Referring physician | |||||||||
| Other (please specify) | B | ||||||||
| HDU7123Q005 | B | Explain why you logged in to MyCGS today. | Text area, no char limit | N | Skip Logic Group | Other Reason for portal | |||
| HDU7123Q006 | A | What enhancements would you like to see added to the myCGS Web Portal? | Text area, no char limit | N | Skip Logic Group | Portal enhancements | |||
| HDU7123Q007 | A | How easy is accessing the information on the myCGS Web Portal? | Very Easy | Radio button, one-up vertical | Single | Y | Skip Logic Group | Easy to access | |
| Easy | |||||||||
| Moderately Difficult | |||||||||
| Very Difficult | |||||||||
| HDU7123Q008 | A | How often do you use the myCGS Web Portal? | Daily | Radio button, one-up vertical | Single | Y | Skip Logic Group | Portal use frequency | |
| A few times a week | |||||||||
| Once a week | |||||||||
| Monthly | |||||||||
| Rarely (less than monthly) | |||||||||
| HDU7123Q009 | What is your primary reason for visiting this site today? | Research a specific question on Medicare policy or billing | Radio button, one-up vertical | Single | Y | Skip Logic Group | Reason for visiting | ||
| Find out about a Local Coverage Determination (LCD) | |||||||||
| Read Medicare publications such as newsletters, articles, etc. | |||||||||
| Download forms | |||||||||
| Access claim status and/or beneficiary eligibility | |||||||||
| Find general Medicare program information | |||||||||
| Learn of, or register for, workshops, seminars or other training events | |||||||||
| Find information on fees or fee schedules | |||||||||
| Take an on-line training course | |||||||||
| Find contact information | |||||||||
| Find enrollment information | |||||||||
| Other (please specify) | A | ||||||||
| HDU7123Q010 | A | Please explain why you visited our website today. | Text field, <100 char | N | Skip Logic Group | Other_Primary reason | |||
| HDU7123Q011 | How did you primarily look for information on the website today? | Left navigation bar | N | Radio button, one-up vertical | Single | Y | Skip Logic Group | Look for Info | |
| Quick links on the right side of the page | N | ||||||||
| Searched using the site search feature | |||||||||
| Other (please specify) | O | ||||||||
| HDU7123Q012 | O | Please explain how you primarily looked for information on the website today. | Text area, no char limit | N | Skip Logic Group | OE_Look for Info | |||
| HDU7123Q013 | N | How would you describe your navigation experience on the website today? (Please select all that apply.) | Some links did not take me where I expected or were broken | E | Checkbox, one-up vertical | Multi | Y | Skip Logic Group | Navigation Experience |
| There were too many navigation options to choose from | |||||||||
| I had no difficulty browsing on this site | Mutually Exclusive | ||||||||
| Other | G | ||||||||
| HDU7123Q014 | E | What specific links did not take you where they should have? | Text area, no char limit | Single | N | Skip Logic Group | Nav links wrong path | ||
| HDU7123Q015 | G | Please explain your navigation experience on the website today. | Text area, no char limit | Single | N | Skip Logic Group | Other_Nav Experience | ||
| HDU7123Q016 | Did you accomplish your goal in coming to the site today? | Yes | Radio button, one-up vertical | Single | Y | Skip Logic Group | Accomplish Goal | ||
| No | C, D | ||||||||
| HDU7123Q017 | C | Why didn't you accomplish your goal? | Text area, no char limit | N | Skip Logic Group | Why Not Accomplish | |||
| HDU7123Q018 | D | Please tell us what you were trying to do or find. | Text area, no char limit | Single | N | Skip Logic Group | Trying to Find | ||
| HDU7123Q019 | If you could identify one improvement to the website, what would that improvement be? | Text area, no char limit | N | Web Improvement | |||||
| HDU7123Q020 | If you could identify one improvement to the myCGS secure web portal what would that improvement be? | Text area, no char limit | N | Secure Improvement | |||||
| HDU7123Q021 | Please provide your work email address if you would like CGS to contact you regarding your feedback (must be 18+). | Text field, <100 char | N | ||||||
Sheet 4: CQs (9-7-18)
| Model Name | CMS - CGS DME MAC B V2 | ||||||||
| Model ID | 140lwY4cIZNwMRBBopI1tw4C | underlined & italicized: RE-ORDER | |||||||
| Partitioned | 2MQ | pink: ADDITION | |||||||
| Date | blue + -->: REWORDING | ||||||||
| CMS - CGS CME MAC B V2 CUSTOM QUESTION LIST | |||||||||
| QID (Group ID) |
Skip Logic Label | Question Text | Answer Choices (limited to 50 characters) |
Skip to | Type (select from list) | Single or Multi | Required Y/N |
Special Instructions | CQ Label |
| HDU7123Q001 | Which best describes you? | Supplier of medical equipment or supplies | Radio button, one-up vertical | Single | Y | Skip Logic Group | Best describes you | ||
| Staff of provider/supplier working primarily with billing/insurance | |||||||||
| Administrative staff of a provider/supplier | |||||||||
|
|
Provider of medical services | ||||||||
| Billing service | |||||||||
| Other staff of a provider/supplier | |||||||||
| Consultant or attorney | |||||||||
| Other (please specify) | A | ||||||||
| JIB0145997 | A | What best describes you? | Text area, no char limit | N | Skip Logic Group | OE_Role | |||
| HDU7123Q002 | In the last 30 days, how many times have you visited this website? | This is my first time | Radio button, one-up vertical | Single | Y | Visit frequency | |||
| Once or twice | |||||||||
| Three or four times | |||||||||
| More than once per week but not every day | |||||||||
| Every day | |||||||||
| HDU7123Q003 | Did you log in to the myCGS Web Portal today? | Yes | A | Radio button, one-up vertical | Y | Skip Logic Group | Log In | ||
| No | |||||||||
| HDU7123Q004 | A | What is your primary reason for logging in to the myCGS Web Portal today? | Eligibility | Radio button, one-up vertical | Single | Y | Skip Logic Group | Reason for portal | |
| Claim status | |||||||||
| CMN information | |||||||||
| Referring physician | |||||||||
| Other (please specify) | B | ||||||||
| HDU7123Q005 | B | Explain why you logged in to MyCGS today. | Text area, no char limit | N | Skip Logic Group | Other Reason for portal | |||
| HDU7123Q006 | A | What enhancements would you like to see added to the myCGS Web Portal? | Text area, no char limit | N | Skip Logic Group | Portal enhancements | |||
| HDU7123Q007 | A | How easy is accessing the information on the myCGS Web Portal? | Very Easy | Radio button, one-up vertical | Single | Y | Skip Logic Group | Easy to access | |
| Easy | |||||||||
| Moderately Difficult | |||||||||
| Very Difficult | |||||||||
| HDU7123Q008 | A | How often do you use the myCGS Web Portal? | Daily | Radio button, one-up vertical | Single | Y | Skip Logic Group | Portal use frequency | |
| A few times a week | |||||||||
| Once a week | |||||||||
| Monthly | |||||||||
| Rarely (less than monthly) | |||||||||
| HDU7123Q009 | What is your primary reason for visiting this site today? | Research a specific question on Medicare policy or billing | Radio button, one-up vertical | Single | Y | Skip Logic Group | Reason for visiting | ||
| Find out about a Local Coverage Determination (LCD) | |||||||||
| Read Medicare publications such as newsletters, articles, etc. | |||||||||
| Download forms | |||||||||
| Access claim status and/or beneficiary eligibility | |||||||||
| Find general Medicare program information | |||||||||
| Learn of, or register for, workshops, seminars or other training events | |||||||||
| Find information on fees or fee schedules | |||||||||
| Take an on-line training course | |||||||||
| Find contact information | |||||||||
| Find enrollment information | |||||||||
| Other (please specify) | A | ||||||||
| HDU7123Q010 | A | Please explain why you visited our website today. | Text field, <100 char | N | Skip Logic Group | Other_Primary reason | |||
| HDU7123Q011 | How did you primarily look for information on the website today? | Left navigation bar | N | Radio button, one-up vertical | Single | Y | Skip Logic Group | Look for Info | |
| Quick links on the right side of the page | N | ||||||||
| Searched using the site search feature | |||||||||
| Other (please specify) | O | ||||||||
| HDU7123Q012 | O | Please explain how you primarily looked for information on the website today. | Text area, no char limit | N | Skip Logic Group | OE_Look for Info | |||
| HDU7123Q013 | N | How would you describe your navigation experience on the website today? (Please select all that apply.) | Some links did not take me where I expected or were broken | E | Checkbox, one-up vertical | Multi | Y | Skip Logic Group | Navigation Experience |
| There were too many navigation options to choose from | |||||||||
| I had no difficulty browsing on this site | Mutually Exclusive | ||||||||
| Other | G | ||||||||
| HDU7123Q014 | E | What specific links did not take you where they should have? | Text area, no char limit | Single | N | Skip Logic Group | Nav links wrong path | ||
| HDU7123Q015 | G | Please explain your navigation experience on the website today. | Text area, no char limit | Single | N | Skip Logic Group | Other_Nav Experience | ||
| HDU7123Q016 | Did you accomplish your goal in coming to the site today? | Yes | Radio button, one-up vertical | Single | Y | Skip Logic Group | Accomplish Goal | ||
| No | C, D | ||||||||
| HDU7123Q017 | C | Why didn't you accomplish your goal? | Text area, no char limit | N | Skip Logic Group | Why Not Accomplish | |||
| HDU7123Q018 | D | Please tell us what you were trying to do or find. | Text area, no char limit | Single | N | Skip Logic Group | Trying to Find | ||
| HDU7123Q019 | If you could identify one improvement to the website, what would that improvement be? | Text area, no char limit | N | Web Improvement | |||||
| HDU7123Q020 | If you could identify one improvement to the myCGS secure web portal what would that improvement be? | Text area, no char limit | N | Secure Improvement | |||||
| HDU7123Q021 | Please provide your work email address if you would like CGS to contact you regarding your feedback (must be 18+). | Text field, <100 char | N | ||||||
Sheet 5: CQs (1-4-17)
| Model Name | CMS - CGS DME MAC B V2 | ||||||||
| Model ID | 140lwY4cIZNwMRBBopI1tw4C | underlined & italicized: RE-ORDER | |||||||
| Partitioned | 2MQ | pink: ADDITION | |||||||
| Date | blue + -->: REWORDING | ||||||||
| CMS - CGS CME MAC B V2 CUSTOM QUESTION LIST | |||||||||
| QID (Group ID) |
Skip Logic Label | Question Text | Answer Choices (limited to 50 characters) |
Skip to | Type (select from list) | Single or Multi | Required Y/N |
Special Instructions | CQ Label |
| HDU7123Q001 | Which best describes you? | Supplier of medical equipment or supplies | Radio button, one-up vertical | Single | Y | Skip Logic Group | Best describes you | ||
| Staff of provider/supplier working primarily with billing/insurance | |||||||||
| Administrative staff of a provider/supplier | |||||||||
|
|
Provider of medical services | ||||||||
| Billing service/Clearinghouse | |||||||||
| Other staff of a provider/supplier | |||||||||
| Consultant or attorney | |||||||||
| Other (please specify) | A | ||||||||
| A | What best describes you? | Text area, no char limit | N | Skip Logic Group | OE_Role | ||||
| HDU7123Q002 | In the last 30 days, how many times have you visited this website? | This is my first time | Radio button, one-up vertical | Single | Y | Visit frequency | |||
| Once or twice | |||||||||
| Three or four times | |||||||||
| More than once per week but not every day | |||||||||
| Every day | |||||||||
| HDU7123Q003 | Did you log in to the myCGS Web Portal today? | Yes | A | Radio button, one-up vertical | Y | Skip Logic Group | Log In | ||
| No | |||||||||
| HDU7123Q004 | A | What is your primary reason for logging in to the myCGS Web Portal today? | Eligibility | Radio button, one-up vertical | Single | Y | Skip Logic Group | Reason for portal | |
| Claim status | |||||||||
| CMN information | |||||||||
| Referring physician | |||||||||
| Other (please specify) | B | ||||||||
| HDU7123Q005 | B | Explain why you logged in to MyCGS today. | Text area, no char limit | N | Skip Logic Group | Other Reason for portal | |||
| HDU7123Q006 | A | What enhancements would you like to see added to the myCGS Web Portal? | Text area, no char limit | N | Skip Logic Group | Portal enhancements | |||
| HDU7123Q007 | A | How easy is accessing the information on the myCGS Web Portal? | Very Easy | Radio button, one-up vertical | Single | Y | Skip Logic Group | Easy to access | |
| Easy | |||||||||
| Moderately Difficult | |||||||||
| Very Difficult | |||||||||
| HDU7123Q008 | A | How often do you use the myCGS Web Portal? | Daily | Radio button, one-up vertical | Single | Y | Skip Logic Group | Portal use frequency | |
| A few times a week | |||||||||
| Once a week | |||||||||
| Monthly | |||||||||
| Rarely (less than monthly) | |||||||||
| HDU7123Q009 | What is your primary reason for visiting this site today? | Radio button, one-up vertical | Single | Y | Skip Logic Group | Reason for visiting | |||
| Research a specific question on Medicare policy or billing | |||||||||
| Find out about a Local Coverage Determination (LCD) | |||||||||
| Read Medicare publications such as newsletters, articles, etc. | |||||||||
| Download forms | |||||||||
| Access claim status and/or beneficiary eligibility | |||||||||
| Find general Medicare program information | |||||||||
| Learn of, or register for, workshops, seminars or other training events | |||||||||
| Find information on fees or fee schedules | |||||||||
| Take an on-line training course | |||||||||
| Find contact information | |||||||||
| Find enrollment information | |||||||||
| Other (please specify) | A | ||||||||
| HDU7123Q010 | A | Please explain why you visited our website today. | Text field, <100 char | N | Skip Logic Group | Other_Primary reason | |||
| HDU7123Q011 | How did you primarily look for information on the website today? | Left navigation bar | N | Radio button, one-up vertical | Single | Y | Skip Logic Group | Look for Info | |
| Quick links on the right side of the page | N | ||||||||
| Searched using the site search feature | |||||||||
| Other (please specify) | O | ||||||||
| HDU7123Q012 | O | Please explain how you primarily looked for information on the website today. | Text area, no char limit | N | Skip Logic Group | OE_Look for Info | |||
| HDU7123Q013 | N | How would you describe your navigation experience on the website today? (Please select all that apply.) | Some links did not take me where I expected or were broken | E | Checkbox, one-up vertical | Multi | Y | Skip Logic Group | Navigation Experience |
| There were too many navigation options to choose from | |||||||||
| I had no difficulty browsing on this site | Mutually Exclusive | ||||||||
| Other | G | ||||||||
| HDU7123Q014 | E | What specific links did not take you where they should have? | Text area, no char limit | Single | N | Skip Logic Group | Nav links wrong path | ||
| HDU7123Q015 | G | Please explain your navigation experience on the website today. | Text area, no char limit | Single | N | Skip Logic Group | Other_Nav Experience | ||
| HDU7123Q016 | Did you accomplish your goal in coming to the site today? | Yes | Radio button, one-up vertical | Single | Y | Skip Logic Group | Accomplish Goal | ||
| No | C, D | ||||||||
| HDU7123Q017 | C | Why didn't you accomplish your goal? | Text area, no char limit | N | Skip Logic Group | Why Not Accomplish | |||
| HDU7123Q018 | D | Please tell us what you were trying to do or find. | Text area, no char limit | Single | N | Skip Logic Group | Trying to Find | ||
| HDU7123Q019 | If you could identify one improvement to the website, what would that improvement be? | Text area, no char limit | N | Web Improvement | |||||
| HDU7123Q020 | If you could identify one improvement to the myCGS secure web portal what would that improvement be? | Text area, no char limit | N | Secure Improvement | |||||
| HDU7123Q021 | Please provide your email address if you would like CGS to contact you regarding your feedback (must be 18+). | Text field, <100 char | N | ||||||
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| File Modified | 0000-00-00 |
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