CMS-10770 IPRO Collaborator Drug Safety Survey

DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Your Opinion Matters

We would appreciate if you would take a few minutes to complete the following questionnaire
regarding your experience working with IPRO. Your responses will be kept private to the extent
provided by law. Information provided by you is voluntary and your decision whether or not to
participate in this survey will not affect Medicare/Medicaid reimbursements to your organization.
This survey is for people who are involved with the Drug Safety Program.
Please click on the "Next" button below and after each question. Please click "Done" at the end of the
survey to capture your responses.
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 voluntary information collection is TBD. The expiration date is TBD.
The purpose of this voluntary information collection request is to collect feedback about the Care
Transitions Program. The end goal of this effort is to collect actionable data to help improve the
overall customer experience. The time required to complete this voluntary information collection is
estimated to average 10 minutes per response, including the time to review instructions 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. ****CMS
Disclosure**** Please do not send applications, claims, payments, medical records or any documents
containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated
OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have
questions about the survey please contact [email protected].

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DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 1: Information About You

1. Who contributed in responding to this survey? (Check each that applies.)
Administrator

HIV Program Administrator

AIMS Liaison

Infection Control Specialist

Clinical Pharmacist

IPRO Liaison

County Representative

IPRO HCQIP Liaison

Data Contact/Encounter Data Liaison

Managed Care Organization Representative

Director of Nursing

Medical Assistant

Director, Patient Services

Medical Director

Director of Pharmacy

Medical Records Director

ESRD Liaison

NHQI Liaison

Facility Administrator

Nurse Manager

Head Nurse

Office Manager

HEDIS/QARR Liaison

Physician

HIM Director

QA/QM/UR/CM Director

HIV Medical Director

Social Worker

Other (please specify)

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DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 1: Information About You

2. How long have you, the respondent (not your organization), been working with IPRO? If multiple people are
responding jointly to this questionnaire, the respondent with the longest working history with IPRO should
select the appropriate answer. (Check only one box).
Less than 12 months
Between 12-24 months
More than 24 months

DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 2: Overall Impression

Please indicate the extent you agree or disagree with the following statements on a scale of 1 to 6 with
1 being "Strongly Disagree" and 6 being "Strongly Agree", by checking the appropriate box.

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* 3. My overall impression of my organization's working relationship with IPRO's Drug Safety Project Team is
positive.
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

N/A

DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 2: Overall Impression

* 4. You rated IPRO unfavorably for the question, "My overall impression of my organization's working
relationship with IPRO's Drug Safety Project Team is positive." Please explain how we can improve in this
area.

DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 2: Overall Impression

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* 5. When contacting IPRO, I can easily reach an appropriate person to assist me.
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

N/A

DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 2: Overall Impression

* 6. You rated IPRO unfavorably for the question, "When contacting IPRO, I can easily reach an appropriate
person to assist me." Please explain how we can improve in this area.

DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 2: Overall Impression

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* 7. IPRO staff is responsive in following up with questions or issues I have.
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

N/A

DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 2: Overall Impression

* 8. You rated IPRO unfavorably for the question, "IPRO staff is responsive in following up with questions or
issues I have." Please explain how we can improve in this area.

DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 2: Overall Impression

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* 9. I am treated respectfully and with courtesy by IPRO staff.
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

N/A

DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 2: Overall Impression

* 10. You rated IPRO unfavorably for the question, "I am treated respectfully and with courtesy by IPRO staff".
Please explain how we can improve in this area.

DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 3: IPRO Drug Safety Program Activities

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11. IPRO's Drug Safety Program's technical assistance supports my organization's quality improvement
activities.
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

NA

DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 3: IPRO Drug Safety Program Activities

* 12. You rated IPRO unfavorably for the question, "IPRO's Drug Safety Program's technical assistance
supports my organization's quality improvement activities." Please explain how we can improve in this area.

DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 3: IPRO Drug Safety Program Activities

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13. IPRO's Drug Safety Program promotes educational material produced by experts (e.g.,
Anticoagulation/Diabetes/Opioid, Discharge Communication tools, MARQUIS Medication Reconciliation
toolkit, Management of Anticoagulation in the PeriProcedural Period mobile app, etc.) that can be used by my
organization for QI efforts.
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

NA

DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 3: IPRO Drug Safety Program Activities

* 14. You rated IPRO unfavorably for the question, "IPRO's Drug Safety Program promotes educational
material produced by experts (e.g., Anticoagulation/Diabetes/Opioid, Discharge Communication
tools, MARQUIS Medication Reconciliation toolkit, Management of Anticoagulation in the PeriProcedural
Period mobile app, etc.) that can be used by my organization for QI efforts. Please explain how we can
improve in this area.

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DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 3: IPRO Drug Safety Program Activities

15. IPRO’s teleconferences and webinar meetings regarding medication safety issues are valuable to our
organization and professional staff.
Strongly Disagree

Disagree

Slightly Disagree

Slightly Agree

Agree

Strongly Agree

NA

DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 3: IPRO Drug Safety Program Activities

* 16. You rated IPRO unfavorably for the question, "IPRO’s teleconferences and webinar meetings regarding
medication safety issues are valuable to our organization and professional staff. Please explain how we can
improve in this area.

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DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Section 4: Comments

17. Please use the following area to provide your feedback on a) recommendations on how IPRO could
improve customer service to your organization, and, b) any examples of exceptional customer service and
support received from our IPRO staff.

18. Would you like to be contacted by a member of the IPRO staff regarding your answers to this survey?
No
Yes (provide contact information below)

19. Please enter your contact information below. (Please complete if you wish to be contacted.)
Name:
Company:
Address:
Address 2:
City/Town:
State:

-- select state --

ZIP:
Country:
Email Address:
Phone Number:

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DRAFT IPRO Drug Safety Program Collaborator Survey (2022)
Comments

Thank you for completing this survey.

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