Document
Proposed Qualtrics Survey Script
ICR 202609-0938-011 · OMB 0938-1382 · Object 172936300.
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Document Metadata
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | Proposed Qualtrics Survey Script |
| Author | Rynes, Scott (CMS/OSPR) |
| Last Modified By | Writer |
| File Modified | 2026-09-11 |
| File Created | 2026-10-10 |
| Conversion State | complete |
Extracted Text
Proposed Qualtrics Survey Script:
1. Overall, how satisfied were you with your experience working with CMS? (1 – Very Dissatisfied, 2 – Somewhat Dissatisfied, 3 – Neutral, 4 – Somewhat Satisfied, 5 – Very Satisfied)
2. How clear was the information you received throughout the process? (1 – Not at all Clear, 2 – Slightly Clear, 3 – Moderately Clear, 4 – Very Clear, 5 – Extremely Clear)
3. How satisfied were you with the timeliness of your request? (1 – Very Dissatisfied, 2 – Somewhat Dissatisfied, 3 – Neutral, 4 – Somewhat Satisfied, 5 – Very Satisfied)
4. What is one thing CMS could improve to make this process clearer or easier? (Free Text)
5. What are aspects of this process that you found especially useful when working with CMS? (Free Text)
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 0938-1382. This information collection is to evaluate overall satisfaction with the CMS/OEDA Salesforce Customer Relationship Management (CRM) system and to further streamline the data request experience for external stakeholders. The time required to complete this information collection is estimated to average less than 3 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is voluntary. 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 or concerns regarding where to submit your documents, please contact James Krometis ([email protected]).