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

Document [xlsx]
Download: xlsx | pdf

Overview

Welcome and Thank You Text
Updated Model
Current CQs
CQs (9-7-18)
CQs (1-4-17)


Sheet 1: Welcome and Thank You Text

Model Instance Name:








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







































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.























































































































































Thank You Text Example


















Thank You Text














Thank you for your time in completing this survey. Your input is very valuable and will be taken into consideration.



















































































































































































































































































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.


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 red & strike-through: DELETE





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
Email






















































































































































































Sheet 4: CQs (9-7-18)

Model Name
CMS - CGS DME MAC B V2 red & strike-through: DELETE





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
Email






















































































































































































Sheet 5: CQs (1-4-17)

Model Name
CMS - CGS DME MAC B V2 red & strike-through: DELETE





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



1-5 times








6-10 times








more than 10 times








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? Log in to myCGS secure web portal
Radio button, one-up vertical Single Y Skip Logic Group Reason for visiting



View Local Coverage Determination (LCD)








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 E







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
Email





















































































































































































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