CMS-10732 Customer and Stakeholder Feedback: Medicare Beneficiary

1. The session I attended was relevant to me.

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

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

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

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

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

… I will explore Medicare.gov and/or the Medicare
Plan Finder to fnd out more about my Medicare
coverage options.
… I will take a look at the Medicare and You
handbook.
… I will call my local SHIP counselor for more
information.
… I will contact my current health plan.
… I will talk to my doctor or pharmacist.
… Other. Please specify

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.

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