CMS-10732 Customer and Stakeholder Feedback: Providers/Suppliers

1. The session I attended was relevant to me.

Strongly agree
Somewhat agree
Neither agree nor disagree
Somewhat disagree
Strongly disagree

2. The CMS presenter(s) was/were knowledgeable
about the subject matter.

Strongly agree
Somewhat agree
Neither agree nor disagree
Somewhat disagree
Strongly disagree

3. If your session covered more than one topic, which

topic(s) was/were of greatest interest or importance
to you?
Please specify

5. What topic(s) do you wish CMS had covered (but
didn’t)? We’ll try to address them next time.
Please specify

6. How do you plan to use the information you gathered
from this CMS session? Select all that apply.

… I will explore the website and/or resources
provided to learn more about the topic(s).
… I will take a look at the proposed rule and may or
will provide written comments to CMS.
… I am not interested in submitting comments to
CMS about this proposed rule.
… I will consider responding to CMS’ Request for
Information.
… I will contact CMS for more information. Consider
contacting your local CMS regional offce at
____________________________.
… I will be sure to share this information with my
patients/clients.
… Other. Please specify

4. How much have your skills or knowledge of this/
these topic(s) improved because of this session?

A great deal
A lot
A moderate amount
A little
None at all

7. Are there any additional comments or suggestions
you have to improve this session for the future?
Thank you for your feedback! Please specify

PRA Disclosure Statement This collection of information request is directly related to the President’s Management Agenda (PMA), specifcally Priority Areas for
Transformation, CAP Goal 4, Improving Customer Experience with Federal Services. The collection consists of a voluntary evaluation that is associated with the PMA
objective of providing a modern, streamlined, and responsive customer experience across Government. Under the Privacy Act of 1974 any personally identifying
information obtained will be kept private to the extent of the law.
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 0938-1185 (CMS-10732). 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 Offcer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

PS