CMS-10598 Stakeholder Onsite Evaluation Survey

OMB control number: 0938-1331

Expiration Date: XX/XX/XXXX

Onsite (Conference or In Person) Training Event Survey

Below is a sample Onsite Post-Training Survey. The surveys are provided to event participants electronically and in hardcopy. Surveys evaluating multiple sessions and dates will include the dates and titles of all sessions to be evaluated. Surveys are voluntary and only provided to training participants who attended the event.

Stakeholder Training Evaluation Form

[Session Title]

[Dates] § [Location]

Day [X]

Please take a few minutes to complete the relevant section(s) of this evaluation form. Your feedback will assist CMS in determining the content and direction of subsequent training sessions. 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 — Sessions

Please indicate your level of agreement with the following statements regarding [Session Title]

(Select one response per statement.)

[Session Title]	Strongly Agree	Agree	Disagree	Strongly Disagree	Not Applicable
Content was presented in an organized manner.	¢	¢	¢	¢	¢
Information regarding resources related to the topic of this session was provided.	¢	¢	¢	¢	¢
Session met the stated learning objectives.	¢	¢	¢	¢	¢
Information provided during this session will be useful to my organization	¢	¢	¢	¢	¢
In general, the session met my expectations.	¢	¢	¢	¢	¢

Additional Comments:

Section B— Training Logistics

<ONSITE RESPONDENT INSTRUMENT> How satisfied were you with each of the following aspects of the [Event Title] training? (Select one response for each aspect.)

Aspect	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied	Not Applicable
REGTAP registration process	¢	¢	¢	¢	¢
REGTAP onsite training event page	¢	¢	¢	¢	¢
Helpfulness of onsite staff	¢	¢	¢	¢	¢
Onsite Registration check-in process	¢	¢	¢	¢	¢
Session location and accessibility	¢	¢	¢	¢	¢
Break(s) provided during the training	¢	¢	¢	¢	¢
Visibility of presentation slides and visual aids	¢	¢	¢	¢	¢
Audibility of the speaker(s)	¢	¢	¢	¢	¢
Question and Answer (Q&A) process or mechanism (Item contingent upon onsite training format)	¢	¢	¢	¢	¢
Lunch logistics (Item contingent upon onsite training format)	¢	¢	¢	¢	¢
Breakout session registration (Item contingent upon onsite training format)	¢	¢	¢	¢	¢
Partner tables (Item contingent upon onsite training format)	¢	¢	¢	¢	¢

Additional Comments:

<INSTRUMENT FOR REMOTE RESPONDENTS PARTICIPATING ONLINE > How satisfied were you with each of the following aspects of the [Event Title] training?
(Select one response for each aspect.)

Aspect	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied	Not Applicable
Webinar log-in	¢	¢	¢	¢	¢
Webinar functionality	¢	¢	¢	¢	¢
Audibility of the speaker(s)	¢	¢	¢	¢	¢
Question and Answer (Q&A) process	¢	¢	¢	¢	¢

Additional Comments:

Section C - General Comments and Recommendations

<ONSITE RESPONDENT INSTRUMENT> If you expressed dissatisfaction with any aspect of this training, please provide a brief description of why you were dissatisfied in the space below.

Event Logistics:

Event Facilitation and Content:

<PROGRAMMER INSTRUCTION: INSTRUMENT FOR REMOTE RESPONDENTS PARTICIPATING ONLINE AND WERE DISSATISFIED OR VERY DISSATISFIED WITH ANY ASPECT> You expressed dissatisfaction with at least one aspect of this training. Please provide a brief description of why you were dissatisfied in the space below.

Event Logistics:

Event Facilitation and Content:

What did you like most about this training?

What recommendations, if any, do you have for future [Event Title] training topics?

Do you have any general comments regarding the [Event Title] training?

Section D – Background Information

Which of the following best describes your organization? (Select one response only.)     

       

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

Which of the following best describes your role within your organization? (Select one response only.)      

       

r Chief Executive Officer r Chief Financial Officer r Compliance Staff

r Agent r Broker r CMS Staff

r Business/Program Analyst r Third Party Submitter r CMS Contractor

r Finance/Revenue Staff r Coder/Data Analyst r Operations Staff

r Risk Adjustment Staff r Program/Project Manager r Information rTechnology Staff r Consultant

r Industry Association Representative r Quality Assurance/Quality Control Staff

r Other (Specify): _________________________________________

State represented (States will be prelisted on hardcopy instruments and will be included in dropdown format on electronic surveys.)

<ONSITE RESPONDENT INSTRUMENT> What is your home state?

r Alabama r Alaska r Arizona r Arkansas r California r Colorado r Connecticut r Delaware r District of Columbia

r Florida r Georgia r Hawaii r Idaho r Illinois r Indiana r Iowa r Kansas r Kentucky

r Louisiana r Maine r Maryland r Massachusetts r Michigan r Minnesota r Mississippi r Missouri r Montana

r Nebraska r Nevada r New Hampshire r New Jersey r New Mexico r New York r North Carolina r North Dakota

r Ohio r Oklahoma r Oregon r Pennsylvania r Rhode Island r South Carolina r South Dakota r Tennessee

r Texas r Utah r Vermont r Virginia r Washington r West Virginia r Wisconsin r Wyoming

<PROGRAMMER INSTRUCTION: INSTRUMENT FOR REMOTE RESPONDENTS PARTICIPATING ONLINE>

r Alabama r Alaska r Arizona r Arkansas r California r Colorado r Connecticut r Delaware r District of Columbia

r Florida r Georgia r Hawaii r Idaho r Illinois r Indiana r Iowa r Kansas r Kentucky

r Louisiana r Maine r Maryland r Massachusetts r Michigan r Minnesota r Mississippi r Missouri r Montana

r Nebraska r Nevada r New Hampshire r New Jersey r New Mexico r New York r North Carolina r North Dakota

r Ohio r Oklahoma r Oregon r Pennsylvania r Rhode Island r South Carolina r South Dakota r Tennessee

r Texas r Utah r Vermont r Virginia r Washington r West Virginia r Wisconsin r Wyoming

Thank you for completing the [Event Title] Evaluation.

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.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and confidential.  It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information.  Unauthorized disclosure may result in prosecution to the fullest extent of the law.

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