Form #4 Form #4 Screen Shots of Data Submission

Figure 1. Public/Login or Registration Page – Provides submission information and a link for users to
register or log in.

Figure 2 Registration – Participants are requested to enter their contact information, identify their role,
as a sponsor, coalition or vendor. Based on this information, system administrators will approve/reject
the registration. If approved, the system automatically sends an email with the login information.

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by
Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that
could identify you will not be disclosed unless you have consented to that disclosure.

Figure 3. Home Page. Outlines each of the steps for data submission process.

Figure 4. Plan Information - Users add and edit information for each health plan.

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this
survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you
have consented to that disclosure.

Figure 5. Submit DUA - Users upload the Data Use Agreement (DUA in Adobe Acrobat (pdf) format to
the submission system. System administrators then review DUAs and approve/reject the submitted
document.

Figure 6. Submit Questionnaire - Users upload questionnaire documents in MS Word (doc), Adobe
Acrobat (pdf) Text (txt) or Rich Text Format (rtf) format to the submission system and identify which
type of questionnaire they are submitting. System administrators then review questionnaires and
approve/reject the submitted document.

Figure 7. Submit Data File Page – Users upload data files from their local computer. Each file
submitted requires information about how the survey was administered. Uploaded files are evaluated in
real-time to ensure they meet the basic required format. If not, users receive immediate feedback. Once a
file is accepted, the data file is loaded it to the database.

Figure 8. View Submission Status – Users can view the status of their account at any time during the
submission process for all submissions in their account.