CMS-10766 CMS-10766.Instrument for COVID-19 Campaign Page Feedback

Overall COVID-19 Campaign Feedback Survey

* denotes a response is required 

Q1*. Was this page helpful?

• Yes

• No

{Note: If ‘Yes’ is selected show Q2-yes, if ‘No’ is selected show Q2-no}

Q2-yes*. I found this page helpful because the content on the page (select all that apply):

• Answers my question(s)

• Is up-to-date

• Is trustworthy

• Is clearly written

• Other [open text box]*

Q2-no* I didn’t find this page helpful because the content on the page (select all that apply)

• Isn’t enough information

• Is too much information

• Is confusing

• Is out-of-date

• Other [open text box]*

Q3. What can we do to improve this page?

[Open text box]

Q4*. What was the primary purpose of your visit to this webpage today?

• Get payment rates

• Get coding information

• Get enrollment information

• Get coverage information

• Learn about billing

• Something else [open text box]*

{Note: Show this question when URL is cms.gov/covidvax-provider }

Q5*. Were you able to {pull answer selection from Q4} today?

• Yes

• No

{Note:

Show this question when URL is cms.gov/covidvax-provider

If ‘Something else’ is selected for Q4, this question will ask “Were you able to accomplish your task?”}

Q6*. Which best describes you?

• Provider of medical services

• Supplier of medical equipment or supplies

• Staff of a provider of medical services

• Staff of a supplier of medical equipment or supplies

• Staff of a billing service/clearinghouse

• Consultant or attorney

• Pharmacy

• Public health clinic

• Senior center/retirement community

• Other non-traditional provider [open text box]*

• Other [open text box]*

{Note: If ‘Provider of medical services’ or ‘Staff of a provider of medical services’ is selected, show 6a}

Q6a.* What is your Medicare enrollment type or the enrollment type of your practice or facility?

• Institutional Provider

• Clinic/Group Practice

• Physician

• Non-Physician Practitioner

• Home Health Facility

• Skilled Nursing Facility

• Other [open text box]*

End of survey message:

If ‘Yes’ is selected for Q1, display:

Thanks for taking our survey.

If ‘No’ is selected for Q1, display:

Thanks for taking our survey. We’ll use your response to make your next experience better.

Embedded data to be collected:

• Physical location – based on visitors IP address

• Page Referrer – page the visitor was previously on

• Current Page URL

• Time Spent on Site – records both total time and time focused on site (only when the webpage is opened as the front, “in-focus” window on the computer)

• Unique Visited Page Count – number of different pages’ user visited on the site

• Search term – captures the term the visitor searched to arrive to the website

• Recorded Site History – captures all the sites the visitor has visited that have the project code on the page

Pages to display survey:

• cms.gov/covidvax-provider [Q4 and Q5 on this URL]

• cms.gov/medicare/covid-19/enrollment

• cms.gov/medicare/covid-19/medicare-reimbursement

PRA Disclosure Statement

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 (Expires 11/30/2022).  This is a voluntary information collection. The time required to complete this information collection is estimated to average 1 minute 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.