CMS-10713 Session Evaluation

Session Evaluation
Session #: _____

You may also opt to take this online: [link]

1. Please select the category that best describes your primary institutional affiliation: (Select one)

 Academic Research Institution  Health Provider Organization  Advocacy/Policy Organization

 Healthcare Product Manufacturer  Insurance Company  Consumer/Patient

 Government Organization  Health Plan Buyer  Health/Provider System

2. Please rate the following statements about the conference:

   	Poor	Fair	Average	Good	Excellent
   The content of the session
   The format of the session (e.g., panel discussion, dialogue session, the number of speakers, flow, length of session)

3. Please provide additional comments on the session moderator and speakers, content, and format.

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

4. What was the single most valuable takeaway for you from this session?

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

5. Please provide any other comments.

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

Session Evaluation
Session #: _____

You may also opt to take this online: [link]

1. Please select the category that best describes your primary institutional affiliation: (Select one)

 Academic Research Institution  Health Provider Organization  Advocacy/Policy Organization

 Healthcare Product Manufacturer  Insurance Company  Consumer/Patient

 Government Organization  Health Plan Buyer  Health/Provider System

2. Please rate the following statements about the conference:

   	Poor	Fair	Average	Good	Excellent
   The content of the session
   The format of the session (e.g., panel discussion, dialogue session, the number of speakers, flow, length of session)

3. Please provide additional comments on the session moderator and speakers, content, and format.

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

4. What was the single most valuable takeaway for you from this session?

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

5. Please provide any other comments.

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

OMB No: 0938-1297 

Expiration Date 1/31/2019 

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 0938-1297.  The time required to complete this information collection is estimated to average 3 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.  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].    

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OMB No: 0938-1297 

Expiration Date 1/31/2019 

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 0938-1297.  The time required to complete this information collection is estimated to average 3 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.  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].