Form Cms-668b - Post Clinical Laboratory Survey Questionnaire Page 2
Download a blank fillable Form Cms-668b - Post Clinical Laboratory Survey Questionnaire in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Cms-668b - Post Clinical Laboratory Survey Questionnaire with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No.0938-0653
POST CLINICAL LABORATORY SURVEY QUESTIONNAIRE
Please provide your comments about the recent CLIA survey of your laboratory.
Your information and suggestions will be used to evaluate and improve the survey process.
State in which laboratory is located:
Total Annual Volume of Testing:
❏ 1 to 2,000 tests
❏ 2,001 to 25,000 tests
❏ 25,001 to 100,000 tests
❏ 100,001 to 1,000,000 tests
❏ Greater than 1,000,000 tests
Type of Laboratory:
❏ Physician Office
❏ Hospital
❏ Skilled Nursing Facility/Nursing Facility
❏ Home Health Agency
❏ Independent
❏ Other
YES ❏
NO ❏
Did your laboratory receive the Alternate Quality Assessment Survey (paper survey)?
IF NO, GO TO SECTION I. IF YES, START AT SECTION II.
SECTION I - ONSITE SURVEY
Please give your overall impression of the survey. Using a scale from 1 to 5, circle the number that applies.
1. Strongly Disagree
3. Neutral
5. Strongly Agree
a. The survey process was explained clearly.
1
2
3
4
5
b. The survey did not interfere with the delivery of care.
1
2
3
4
5
c. The survey assisted in your understanding of the CLIA requirements.
1
2
3
4
5
d. Deficiencies, if any, were explained clearly so that you understood what the problem was and why.
1
2
3
4
5
N/A
e. If deficiencies were found, the time frame and process for the plan of correction was explained.
1
2
3
4
5
N/A
f. The survey was completed in a reasonable amount of time.
1
2
3
4
5
g. The survey met your laboratory’s expectations.
1
2
3
4
5
AFTER COMPLETING THIS SECTION, SKIP SECTION II, AND GO TO SECTION III AND IV.
SECTION II - ALTERNATE QUALITY ASSESSMENT SURVEY (AQAS)
Please give your overall impression of the survey. Using a scale from 1 to 5, circle the number that applies.
1. Strongly Disagree
3. Neutral
5. Strongly Agree
a. The questions on the AQAS were clear and understandable.
1
2
3
4
5
b. The form was not excessively lengthy.
1
2
3
4
5
c. Your facility made some changes in policies or procedures based on information in the form.
1
2
3
4
5
d. Your facility was able to complete and return the AQAS within 15 days of receipt.
1
2
3
4
5
e. If clarification was needed, you were able to contact the State Agency and receive assistance.
1
2
3
4
5
N/A
f. Your facility would have preferred an onsite survey instead of the AQAS for this survey cycle.
1
2
3
4
5
g. The AQAS is an efficient, effective replacement for an onsite survey.
1
2
3
4
5
SECTION III - GENERAL INFORMATION
a) Please recommend the one single change that would improve your facility’s survey experience.
b) Comments regarding the CLIA survey process in general:
SECTION IV - OPTIONAL INFORMATION
Facility Name
CLIA #
Date of Survey
After completing this questionnaire, please detach it from the cover letter, fold, seal and return it within 2 weeks to the address printed on
the back of this form. The preprinted address is:
Post Clinical Laboratory Survey Questionnaire Response
P.O. Box 8093
Baltimore, Maryland 21244-9942
THANK YOU FOR TAKING THE TIME TO ANSWER THESE QUESTIONS.
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 0938-0653. 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 any 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.
Form CMS-668B (01/12)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical