DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, MD 21244 -1850
Dear Laboratory Director:
Attached is the Post Clinical Laboratory Survey Questionnaire (CMS-668B). The purpose for collecting the
customer satisfaction data on this questionnaire is to evaluate, on a nationwide basis, the laboratory’s satisfaction
with their recent Clinical Laboratory Improvement Amendments (CLIA) survey. The information and suggestions
you provide will be used to evaluate and improve the CLIA survey process.
Your response to this form is entirely voluntary. All information provided in response to the CMS-668B is
considered proprietary, will be kept confidential, and will not be used for compliance purposes. We will release
only aggregate information to our State Agencies. We welcome your comments.
The Post Clinical Laboratory Survey Questionnaire is one page and should take approximately 15 minutes to
complete. We would appreciate it if you would take a moment to complete the questionnaire and return it. Your
comments are important and valued. If you need additional information concerning this questionnaire, please call
(410) 786-3531 or write to the return address listed on the back page of the questionnaire.
INSTRUCTIONS FOR COMPLETING THE QUESTIONNAIRE:
1. If your laboratory received an onsite survey (i.e., a CLIA survey that is usually conducted by your
State Agency), then you should skip Section II.
2. If your laboratory received the Alternative Quality Assessment Survey (i.e., paper CLIA survey of
quality indicators), then please skip Section I.
3. After completing the questionnaire, please detach it from this cover letter, fold, seal, and return it to
the address printed on the back of the form. Please note that this questionnaire is a self-mailer, not
requiring a separate envelope, and that the postage for returning this form has been prepaid.
The authority for the solicitation of this information is section 353 of the Public Health Service Act.
Attachment