Insure Kids Now Customer Feedback Survey

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Completed by
Completed date
Reviewed by
Reviewed date

Insurekidsnow.gov: Site
QID

Q0

Question Type

Descriptive Text

Question Text
InsureKidsNow.gov is looking for your
feedback. Thanks for taking a moment to
tell us about your experience today on
InsureKidsNow.gov!

BLOCK 1: OSAT & HISP

Q1

Multiple Choice (single select)

Which of these best describes you?

Q2

Multiple Choice (single select)

What was the main reason you came to InsureKidsNow.gov today? If yo

Q3

Multiple Choice (single select)

Q4

Multiple Choice (single select)

How satisfied are you with your overall experience on InsureKidsNow.go
Based on my experience on
InsureKidsNow.gov, I trust that
InsureKidsNow is working in the best
interest of the American public.

Multiple Choice (multi-select)

What about today's interaction made the
difference? (Select all that apply)

Q5.2

Multiple Choice (multi-select)

What could have been better? (Select all
that apply)

Q6

Multiple Choice (single select)

If you used the InsureKidsNow.gov search feature, did it help you find w

Q5.1

You told us you were dissatisfied with one
or more parts of your experience. To help
us improve, please tell us why.

Q7.1

Text Entry

Please be specific, but protect your privacy don't include personal information, like
your phone number, address, or Social
Security number.

Q7.2

Text Entry

How can we improve your overall experience on InsureKidsNow.gov? Ple
We thank you for your time spent taking this surve

END OF SURVE

Your response has been recorded.

PRA Disclosure Statement The purpose of the PRA package is to collect voluntary feedback to asssit in websi

Under the Privacy Act of 1974 any personally identifying information obtained will be kept private to the extent of
required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB c
The time required to complete this information collection is estimated to average 2 minutes per response, includi
needed, and complete and review the information collection. If you have comments concerning the accuracy of t
7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-

Survey Options
Incomplete responses are recorded
Survey Title (appears on web browser tab) Insurekidsnow.gov: Site Wide Survey

Insurekidsnow.gov: Site Wide Survey
Answer Choices (if applicable)

Required?

NA

N

Person looking for Health Insurance information or a Dental Provider
Healthcare professional or administrative staff
Government employee
Community Outreach Partner
Other (Please specify)
CHIP eligibility or coverage information
Find a Dentist
Outreach information or materials
Other (Please specify)
Extremely Dissatisfied
Slightly Dissatisfied
Neither satisfied nor dissatisfied
Slightly Satisfied
Extremely Satisfied

Yes
No
I accomplished my task
The website was easy to navigate
Found what I needed quickly
The information was easy to understandSomething else
I did not complete my task
The website was difficult to navigate
It took too long to do what I needed to do
The information was hard to understand
Something else
Yes
No
Does not apply

N

N

Y

Y

Y

Y

N

for your time spent taking this survey.

NA

N

NA

N

END OF SURVEY

response has been recorded.

oluntary feedback to asssit in website development.

d will be kept private to the extent of the law. According to the Paperwork Reduction Act of 1995, no persons are
MB control number. The valid OMB control number for this information collection is 0938-1382 (Exprires: 12/31/2026).
age 2 minutes per response, including the time to review instructions, search existing data resources, gather the data
ments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS,
-26-05, Baltimore, Maryland 21244-1850.

ekidsnow.gov: Site Wide Survey

Randomize
Answer
Display Logic Choices?

N

N

N

N

N

N

N

N

N

N

Y
Display if Q4 = Yes

N

Y
Display if Q4 = No

N

N

N

Display if Q4 = No
Display if Q7.1
does not display

1995, no persons are
382 (Exprires: 12/31/2026).
resources, gather the data
rm, please write to: CMS,

N
N