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
 
A1. Outreach Related to Medicaid Services
A2. Outreach Related to Non-Medicaid Services
B1. Referral, Coordination or Training Related to Medicaid Services
B2. Referral, Coordination or Training Related to Non-Medicaid Services
C1. Transportation or Translation Related to Medicaid Services
C2. Transportation or Translation Related to Non-Medicaid Services
D1. System Coordination/Community Assessment Related to Medicaid Services
D2. System Coordination/Community Assessment Related to Non-Medicaid Services
E. Direct Health Care Services
F. Other Work Activities
 

TimeA1A2B1B2C1C2D1D2EF
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