Form CMS-10804 QPP Site Intercept Survey

Request for Approval under the “Generic Clearance for the Center for Clinical Standards
and Quality IT Product and Support Teams ” (OMB Control Number: 0938-1397)

TITLE OF INFORMATION COLLECTION: Quality Payment Program Site Intercept
Survey

PURPOSE OF COLLECTION:
The Quality Payment Program (QPP) website is visited by thousands of users each day with
various objectives including, but not limited to, checking clinician eligibility status, selecting and
downloading measure specification forms, learning about reporting requirements, submitting
data, and reviewing feedback. These site visitors may include, but are not limited to, clinicians,
office administrators, hospital administrators, third-party intermediaries, and professional
association staff. These visitors rely on the content on the website to be clear, accessible, and up
to date to meet or support clients in meeting CMS regulatory standards and participate in the
Quality Payment Program.
The QPP Site Intercept Survey is designed to collect feedback in real time from site visitors
regarding their satisfaction with the website and their goals when visiting the website. The
survey will be available on the QPP website to provide visitors the opportunity to share their
experience throughout the year. This information will allow the QPP HCD Team to assess visitor
needs and satisfaction to plan enhancements to the digital experience. Information will be
collected through a combination of questions with pre-set responses and open text fields.
Demographic data will be collected to better understand the type of user and segment findings,
but no Personally Identifiable Information (PII) will be included in the Site Intercept Survey.
Estimated time to complete survey is less than 5 minutes.

TYPE OF COLLECTION: (Check one)
[ ] Card Sorting
[ ] Cognitive Testing
[ ] Field Studies
[ ] First Click Tests
[ ] Focus Groups
[ ] Participatory Design
[X] Survey
[ ] Tree Testing
[ ] User Interviews
[ ] Usability Testing
[ ] Other: _______________________
CERTIFICATION:
I certify the following to be true:
1. The collection is voluntary.
2. The collection is low-burden for respondents and low-cost for the Federal Government.
3. The collection is non-controversial and does not raise issues of concern to other federal
agencies.
4. The results are not intended to be disseminated to the public.
5. Information gathered will not be used for the purpose of substantially informing influential
policy decisions.

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6. The collection is targeted to the solicitation of opinions from respondents who have
experience with the program or may have experience with the program in the future.
Digitally signed by

Name:

Andrew J.
Andrew J. Anuszewski -S
2022.01.12
Anuszewski -S Date:
X________________
07:50:24 -05'00'

To assist review, please provide answers to the following question:

PERSONALLY IDENTIFIABLE INFORMATION
1. Is personally identifiable information (PII) collected? [ ] Yes [ X] No
2. If Yes, will any information that is collected be included in records that are subject to the
Privacy Act of 1974? [ ] Yes [ ] No
3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No
GIFTS OR PAYMENTS
Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to
participants? [ ] Yes [ X] No
If Yes, describe:
BURDEN HOURS
Category of Respondent

No. of
Respondents
1,200

QPP Users

Participation
Time
0.083 hours
per response

Burden
100
total
hours

Totals
FEDERAL COST
The estimated cost to the Federal government consists of labor and license cost as illustrated
below:
Annual Labor Cost: 64 hours @ $142.00 per hour = $9,088.00
Annual License Cost (HotJar): $1,188.00
Total Cost: $10,276.00

ACTIVITY DETAILS
1. How will you collect the information? (Check all that apply)
[X] Web-based or other forms of social media
[ ] Telephone
[ ] In-person
[ ] Mail

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[ ] Other, Explain.
2. Will interviewers or facilitators be used? [ ] Yes [X] No
3. Who will you collect the information from?
Data will be collected from visitors to the Quality Payment Program website. This may
include, but is not limited to, clinicians, office administrators, hospital administrators, thirdparty intermediaries, and professional associations.
4. How will you ask a respondent to provide this information?
A site intercept survey is series of questions collected through a form on the QPP website.
The questions will be presented to the user during their site visit. Completion of the form is
optional.
5. What will the activity look like?
During a user’s visit to the QPP website, they will be presented an opportunity to complete
the form with questions related to their experience and satisfaction. They form will include a
combination of text entry fields and radio button selectors. If they choose to participate, they
will respond to the questions and click submit to send their responses to the QPP HumanCentered Design team.
6. Please provide your question list.
Share your feedback with QPP [participant will select ‘Next’ button to begin survey]
1) Which
a.
b.
c.
d.
e.
f.
g.

of the following best describes your current role? (Select one)
Clinician
Practice Manager
Compliance Manager
ACO Administrator
Registry/QCDR
Consultant/Educator
Other: [Text Input]

2) How frequently do you visit the QPP website? (Select one)
a. Daily
b. Few times a week
c. Few times a month
d. Few times a year
e. First time visiting
3) Why did you visit the QPP website today?
[Open Text Input]

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4) How easy or difficult was it for you to accomplish your goal on the QPP website today?
(Select one)
Answer scale from 1= Extremely difficult to 5 = Extremely easy
5) Which of the following best describes your level of satisfaction with the QPP website?
(Select one)
Answer scale from 1= Extremely dissatisfied to 5 = Extremely satisfied
6) Please share any additional comments or feedback regarding the QPP website in the
space provided below.
[Open Text Input]
According to the Paperw ork 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 09381397 (Expiration date: 07/31/2024). The time required to complete this information collection is estimated to
average .083 hours 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 w rite 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 w ill not be review ed, forwarded, or retained. If
you have questions or concerns regarding w here to submit your documents, please contact QPP at [email protected]

Please make sure that all instruments, instructions, and scripts are submitted with the
request.
7. When will the activity happen?
Data will be collected in real-time throughout the year to identify patterns in user needs as
they change during the annual program cycle. The team aims to launch the survey beginning
Spring 2022.

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