Form CMS-10598 Stakeholder Onsite Conference Evaluation

OMB 0938-1331 - CMS Onsite Conference Post-Training Evaluation

Below is a sample Conference Post-Training Survey. The surveys are provided to event participants electronically and in hardcopy. Surveys evaluating multiple sessions and dates will include the dates and titles of all sessions to be evaluated. Surveys are voluntary and only provided to training participants who attended the event.

CMS Training Evaluation Form [Session Title]

[Dates]  [Location] Day [X]

Please take a few minutes to complete the relevant section(s) of this evaluation form. Your feedback will assist CMS in determining the content and direction of subsequent training

sessions. Your responses will remain confidential and will be reported in aggregate form only.

Please do not include in your responses any personally identifiable information (PII).

Section A — Sessions

Please indicate your level of agreement with the following statements regarding [Session Title]

(Select one response per statement.)

[Session Title]	Strongly Agree	Agree	Disagree	Strongly Disagree	Not Applicable
Content was presented in an organized manner.					
Information regarding resources related to the topic of this session was provided.					
Session met the stated learning objectives.					
Information provided during this session will be useful to my organization					
In general, the session met my expectations.					

Additional Comments:

Section B— Training Logistics

<ONSITE RESPONDENT INSTRUMENT> How satisfied were you with each of the following aspects of the [Event Title] training? (Select one response for each aspect.)

Aspect	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied	Not Applicable
Helpfulness of onsite staff					
Registration check-in process					
Session location and accessibility					
Break(s) provided during the training					
Visibility of presentation slides and visual aids					
Audibility of the speaker(s)					
Question and Answer (Q&A) process or mechanism (Item contingent upon onsite training format)					
Lunch logistics (Item contingent upon onsite training format)					
Breakout session registration (Item contingent upon onsite training format)					
Partner tables (Item contingent upon onsite training format)					

Additional Comments:

<INSTRUMENT FOR REMOTE RESPONDENTS PARTICIPATING ONLINE > How satisfied were you

with each of the following aspects of the [Event Title] training?

(Select one response for each aspect.)

Aspect	Very Satisfied	Satisfied	Dissatisfied	Very Dissatisfied	Not Applicable
Webinar log-in					
Webinar functionality					
Audibility of the speaker(s)					
Question and Answer (Q&A) process					

Additional Comments:

Section C - General Comments and Recommendations

<ONSITE RESPONDENT INSTRUMENT> If you expressed dissatisfaction with any aspect of this training, please provide a brief description of why you were dissatisfied in the space below.

Event Logistics:

Event Facilitation and Content:

<PROGRAMMER INSTRUCTION: INSTRUMENT FOR REMOTE RESPONDENTS PARTICIPATING ONLINE AND WERE DISSATISFIED OR VERY DISSATISFIED WITH ANY ASPECT> You expressed

dissatisfaction with at least one aspect of this training. Please provide a brief description of why you were dissatisfied in the space below.

Event Logistics:

Event Facilitation and Content:

What did you like most about this training?

What recommendations, if any, do you have for future [Event Title] training topics?

Do you have any general comments regarding the [Event Title] training?

Section D – Background Information

Which of the following best describes your organization? (Select one response only.)

Agents and Brokers

• Agents and Brokers

• Web-brokers/Enhanced Direct Enrollment Entities (EDEs)

Assisters

• Certified Application Counselors (CAC) Designated Organizations (CDO)

• Enrollment Assister Personnel (EAP)

• Federally-Certified Navigators and Navigator Grantee Organizations

• Other Assister Organization

• Primary Care Associations (PCA)

• State-Based Marketplace (SBM) Organization

• State-Based Marketplace - Federal Platform (SBM-FP) Marketplace Assisters

Plans/Issuers/TPAs/PBMs

• CO-OP

• Dental Plan

• Federal Employees Health Benefits (FEHB) Carrier

• Federally Facilitated Marketplace (FFM) Issuers

• Group Health Plan

• Issuer Vendors

• Large Group Market

• Non-Federal Governmental Plan

• Non-Marketplace Issuers

• Off Exchange Individual or Small Group Market

• Other Plan or Issuer Organization

• Pharmacy Benefit Managers (PBMs)

• State Partnership Marketplace (SPM) Issuers

• State-Based Marketplace (SBM) Issuers

• State-Based Marketplace - Federal Platform (SBM-FP) Issuers

• Student Health Plan

• Third Party Administrators (TPAs)

Providers/Facilities

• Air Ambulance Providers

• Ancillary Services

• Community Health Center (CHC)

• Federally Qualified Healthcare Center (FQHC)

• Ground Ambulance

• Health System

• Hospital

• Long-Term Care

• Medical Billing or Revenue Cycle Management

• Medical Specialty Society or Membership Association

• Mental Health Provider

• Other Healthcare Provider

• Physician Office or Group

• Skilled Nursing Facility (SNF)

• Specialist

• Tribal Health Organization

States

• State Administering Entities (AE) - CMS Internal Support

• State Administering Entities (AE) - Security

• State Administering Entities (AE) - Third Party Auditor

• State Agency/State Regulator

• State Reinsurance Entities

Other

• Associations

• Auditor/Potential Initial Validation Auditor (IVA)

• CMS

• Consultant/Contractor

• Employer

• Independent Dispute Resolution Entity (IDRE)

• Independent Review Organization (IRO)

• Law Firm

• Research/Education/Advocacy Organization/Non-Profit

• Other (Specify):

Which of the following best describes your role within your organization? (Select one response only.)

• Chief Executive Officer  Chief Financial Officer  Compliance Staff

• Agent  Broker  CMS Staff

• Business/Program Analyst  Third Party Submitter  CMS Contractor

• Finance/Revenue Staff  Coder/Data Analyst  Operations Staff

• Risk Adjustment Staff  Program/Project Manager  Information

• Technology Staff  Consultant

• Industry Association Representative  Quality Assurance/Quality Control Staff

• Other (Specify):

State represented (States will be prelisted on hardcopy instruments and will be included in dropdown format on electronic surveys.)

<ONSITE RESPONDENT INSTRUMENT> What is your home state?

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia

Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky

Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana

Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota

Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee

Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

<PROGRAMMER INSTRUCTION: INSTRUMENT FOR REMOTE RESPONDENTS PARTICIPATING ONLINE>

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia

Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky

Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana

Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota

Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee

Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Thank you for completing the CMS [Event Title] evaluation.

OMB 0938-1331

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The valid OMB control number for this information collection is 0938-1331. Survey responses to CMS are public information, and there is no personal identifying information collected within this survey.

Survey participation and responses are voluntary. CMS uses this information from the data collection activities to determine the extent to which the goals of each training and support session were achieved and to help CMS make improvements for future training sessions. The time required to complete this information collection is estimated to average 15 minutes 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 write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850 and/or email registrar@regtap.cms.gov. Analysis of data from the evaluations of Computer Based Training (CBT), webinars, and conferences (“events”) address Federal reporting requirements, and goals and objectives for the Affordable Care Act, including: The Government Performance and Results Act (GPRA) Modernization Act of 2010 (Office of Management and Budget, n.d.); The U.S. Department of Health and Human Services’ (HHS) Strategic Plan FY 2022-2026 (HHS, n.d.); and The Center for Medicare and Medicaid Services (CMS) goals for the ACA (2013).

2