Form CMS-10598 Stakeholder Webinar Evaluation Form

OMB 0938-1331 - CMS Training Evaluation Form

Webinars and Webinar-based Q&A Sessions

[Webinar and/or Series Title]

Instructions:

The following instructions will appear on all surveys.

Please take a moment to answer the following questions regarding to the CMS Training <Webinar/Q&A Session >, <Complete Title of Session (including series name, if applicable)> held on <mm/dd/yyyy>. Your feedback will assist CMS in determining the extent to which we achieved the goals of the training and will help CMS to make improvements for future 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: Overall Satisfaction

The following questions will appear in Section A for all sessions.

1. Please rate your level of overall satisfaction with this <Webinar/Q&A Session> session.

   1. Very satisfied

   2. Satisfied

   3. Dissatisfied

   4. Very Dissatisfied Additional Comments:

The following question will appear in Section A for the final session of the month for Webinar, Webinar Q&A or User Group sessions.

2. Please rate your general level of satisfaction with the <Title of Series> sessions held during the month of <Month/Year>.

   1. Very satisfied

   2. Satisfied

   3. Dissatisfied

   4. Very Dissatisfied

   5. Don’t Know/Not Applicable

Additional Comments:

Section B: Session Facilitation and Content

The following questions will appear in Section B for all sessions.

1. Please rate your level of satisfaction with the facilitation of the <Webinar/ Q&A Session>.

   1. Very satisfied

   2. Satisfied

   3. Dissatisfied

   4. Very Dissatisfied Additional Comments:

2. Please indicate your level of agreement with each the following statements regarding the current session. Select one response per statement.

Statement	Strongly Agree	Agree	Disagree	Strongly Disagree	Not Sure	Not Applicable
As a result of this session, I clearly understand the concept of <pre-specified topic>.						
In general, the session met the stated learning objectives						
The information provided during this session will be useful to my organization						

Additional Comments:

3. <FINAL SESSION OF THE MONTH ONLY> To what extent have you utilized the information provided during <Title of Series>, during the month of [Month Year]?

1. To a great extent

2. To a moderate extent

3. To little extent

4. Not at all

4. <FINAL SESSION OF THE MONTH ONLY> To what extent has the information provided during <Title of Series>, during the month of [Month Year] helped you in your role?

1. To a great extent

2. To a moderate extent

3. To little extent

4. Not at all

Section C: Session Logistics

The following question will appear in Section C for all sessions.

1. Please rate your level of satisfaction with each of the following logistical aspects of the webinar.

Select one response for each aspect.

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

Additional Comments:

Section D: Comments and Suggestions

The following questions will appear in Section D for all sessions.

1. (PROGRAMMER INSTRUCTION: IF DISSATISFIED OR VERY DISSATISFIED WITH ANY ASPECT…) If you

expressed dissatisfaction with at least one specific aspect of this session, in the space below, please provide a brief description of why you were dissatisfied.

Session Logistics:

Session Facilitation and Content:

2. What did you like most about this session?

3. What suggestions do you have for future <Title of Session/Title of Series> topics?

4. Do you have any additional comments regarding the <Title of Session> training session or the<Title of Series> series as whole <for a series>?

Section E: Background Information

The following questions in Section E will appear on all surveys.

1. Which of the following best describes your organization? (Select one category that best describes your organization.)

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):

2. (Location of organization (State) (Select one category from dropdown list.) (PROGRAMMER INSTRUCTION: INSERT DROPDOWN LIST.)

3. Which of the following best describes your role within your organization? (Select one category

that best describes your role.)

1. Chief Executive Officer

2. Chief Financial Officer

3. Compliance Staff

4. Agent

5. Broker

6. CMS Staff

7. CMS Contractor

8. Business/Program Analyst

9. Third Party Submitter

10. Finance/Revenue Staff

11. Coder/Data Analyst

12. Operations Staff

13. Risk Adjustment Staff

14. Program/Project Manager

15. Information Technology Staff

16. Consultant

17. Industry Association Representative

18. Quality Assurance/Quality Control Staff

19. State Regulator

20. Issuer Vendor

21. Other (specify):

Thank you for completing the CMS Training 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).