Form CMS-10598 Stakeholder CBT Survey

OMB control number: 0938-1331

Expiration Date: XX/XX/XXXX

Stakeholder Computer-Based Training (CBT) Evaluation Form

Below is a sample Computer-Based Training Survey. The surveys are electronically distributed to participants who complete the CBT. Surveys evaluating CBTs in a series may include multiple CBTs to evaluate or may include individual surveys for each CBT. Surveys are voluntary, and participants can opt out of completing evaluations.

Stakeholder Training Evaluation Form

[CBT Title]

Please take a moment to answer the following questions regarding your experience with the <insert Topic> CBT. Your feedback will assist CMS in determining the extent to which we achieved the goals of the training and will help CMS to make improvements for future trainings. Your responses will remain confidential and will be reported in aggregate form only. Please do not include in your responses any personally identifiable information (PII).

Section A: CBT Logistics

The following questions in Section A will appear on all surveys.

1. Please rate your level of satisfaction with each of the following User Experience aspects of the CBT. Select one response for each aspect.

Aspect	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied	Not Applicable
Ease of navigation					
Narration, screen quality, functionality, and notes <if applicable>					
Audibility					

Additional Comments:

Section B: Content

The following questions in Section B will appear on all surveys.

1. Please indicate your level of agreement with each the following statements regarding the current session. Select one response per statement.

Statement	Strongly Agree	Agree	Disagree	Strongly Disagree	Not Sure	Not Applicable
The learning objectives of the <insert Topic> CBT were clearly explained.						
The information in the <insert Topic> CBT was arranged in a clear and logical way.						
In general, the <insert Topic> CBT met the stated learning objectives.						
As a result of this CBT, I clearly understand the concept of <insert Topic>.						
The <insert Topic> CBT delivered the information I expected to receive.						
The information provided in this <insert Topic> CBT will be useful to my organization.						

Additional Comments:

3. To what extent have you utilized the information provided during the <insert Topic> CBT?

1. To a great extent

2. To a moderate extent

3. To little extent

4. Not at all

4. To what extent has the information provided during the <insert Topic> CBT helped you in your role?

a. To a great extent

b. To a moderate extent

c. To little extent

d. Not at all

Section C: Overall Satisfaction

The following questions in Section C will appear on all surveys.

1. Please rate your level of overall satisfaction with this <insert Topic> CBT.

1. Very satisfied

2. Satisfied

3. Dissatisfied

4. Very Dissatisfied

Additional Comments:

Section D: Comments and Suggestions

The following questions in Section D will appear on all surveys.

1. (PROGRAMMER INSTRUCTION: IF DISSATISFIED OR VERY DISSATISFIED WITH ANY ASPECT…) You expressed dissatisfaction with at least one specific aspect of this CBT, in the space below, please provide a brief description of why you were dissatisfied.

CBT User Experience:

CBT Content:

2. What did you like most about this CBT?

3. What do you believe would help improve future <insert Topic> trainings?

4. What suggestions do you have for future <insert Topic> CBT topics?

5. Do you have any additional comments regarding the <insert Topic> CBT training session?

Section E: Background Information

The following questions in Section E will appear on all surveys.

1. Which of the following best describes your organization? (Select one category that best describes your organization.)

r Agent/Broker/Web-Broker r Non-Marketplace Issuer

r Association r Pharmacy Benefit Manager (PBM)

r Auditor/Potential Initial Validation Auditor (IVA) r State Agency/State Regulator

r Centers for Medicare & Medicaid Services (CMS) r State-Based Marketplace (SBM) Issuer

and other Federal Agencies r State-Based Marketplace-Federal Platform (SMB-FP) Issuer

r Consultant/Contractor r State Partnership Marketplace (SPM) Issuer

r Cooperatives (CO-OP) r State Reinsurance Entity

r Dental Plan r Third Party Administrator (TPA)

r Federally Facilitated Marketplace (FFM) Issuer r Other (Specify): _________________

r Issuer Vendor

r Navigators and Marketplace Assistor

2. Location of organization (State) (Select one category from dropdown list.) (PROGRAMMER INSTRUCTION: INSERT DROPDOWN LIST.)

3. Which of the following best describes your role within your organization? (Select one category that best describes your role.)

1. Chief Executive Officer

2. Chief Financial Officer

3. Compliance Staff

4. Agent

5. Broker

6. CMS Staff

7. CMS Contractor

8. Business/Program Analyst

9. Third Party Submitter

10. Finance/Revenue Staff

11. Coder/Data Analyst

12. Operations Staff

13. Risk Adjustment Staff

14. Program/Project Manager

15. Information Technology Staff

16. Consultant

17. Industry Association Representative

18. Quality Assurance/Quality Control Staff

19. Other (specify):

Thank you for completing the Stakeholder CBT Training evaluation form.

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 0938-1331. The time required to complete this information collection is estimated to average 15 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.

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