EXAMPLE SURVEY

Welcome to the Medicaid Administrative Claiming Survey.

Name: <firstname> <lastname>

Survey:

Thanks for taking the time to fill out this survey, <firstname> <lastname>. You should have received training on how to take this survey, but provided below is a short summary of the features and interface of this form to make your time filling it out as short and simple as possible.


ActivityTime
 
A. School Related / Educational Activities
B1. Medicaid / OHP Outreach
B2. Non-Medicaid / OHP Outreach
C1. Admin of Medicaid / OHP Services
C2. Admin of Non-Medicaid / OHP Services
D1. Medicaid / OHP Transportation
D2. Non-Medicaid / OHP Transportation
E1. Medical Service Program Admin
E2. Non-Medical Services Program Admin
F. Direct Medical Services
 

TimeAB1B2C1C2D1D2E1E2F
7:00 - 7:15 am
7:15 - 7:30 am
7:30 - 7:45 am
7:45 - 8:00 am
8:00 - 8:15 am
8:15 - 8:30 am
8:30 - 8:45 am
8:45 - 9:00 am
9:00 - 9:15 am
9:15 - 9:30 am
9:30 - 9:45 am
9:45 - 10:00 am
10:00 - 10:15 am
10:15 - 10:30 am
10:30 - 10:45 am
10:45 - 11:00 am
11:00 - 11:15 am
11:15 - 11:30 am
11:30 - 11:45 am
11:45 - 12:00 pm
12:00 - 12:15 pm
12:15 - 12:30 pm
12:30 - 12:45 pm
12:45 - 1:00 pm
1:00 - 1:15 pm
1:15 - 1:30 pm
1:30 - 1:45 pm
1:45 - 2:00 pm
2:00 - 2:15 pm
2:15 - 2:30 pm
2:30 - 2:45 pm
2:45 - 3:00 pm
3:00 - 3:15 pm
3:15 - 3:30 pm
3:30 - 3:45 pm
3:45 - 4:00 pm
4:00 - 4:15 pm
4:15 - 4:30 pm
4:30 - 4:45 pm
4:45 - 5:00 pm
5:00 - 5:15 pm
5:15 - 5:30 pm
5:30 - 5:45 pm
5:45 - 6:00 pm
6:00 - 6:15 pm
6:15 - 6:30 pm
6:30 - 6:45 pm
6:45 - 7:00 pm
7:00 - 7:15 pm
7:15 - 7:30 pm
7:30 - 7:45 pm
7:45 - 8:00 pm