Form Clinic User Survey Clinic User Survey Clinic User Survey- Pharmacist

2005 Clinic User Survey

Pharmacy Sites

Draft Mail Questionnaire

May 10, 2005

SURVEY INSTRUCTIONS

• Answer all the questions by checking the box to the left of your answer.

• You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:

 Yes If Yes, Go to Q.1 on Page 1

 No

All information that would let someone identify you or your family will be kept private. We will not share your personal information with anyone without your OK. You may choose to answer this survey or not. If you choose not to, this will not affect the benefits you get. SUBSTITUTE HRSA FOR CAHPS LANGUAGE

If you want to know more about this study, please call XXX-XXXX.

YOUR HEALTH CARE EXPERIENCES AT THIS CLINIC IN THE LAST 6 MONTHS

Q.1. In the last 6 months, did you visit this clinic during regular office hours to get help or advice for yourself?

use an x to mark your answer

1  Yes GO TO Q.2

0  No END SURVEY; THE SURVEY IS ONLY FOR PEOPLE WHO HAVE VISITED THE CLINIC IN THE LAST 6 MONTHS.

Q.2. (If Yes) In the last 6 months, when you visited this clinic during regular office hours, how often did you get the help or advice you needed?

1  Never

2  Sometimes

3  Usually

4  Always

Q3. A health provider could be a general doctor, a specialist doctor, a chiropractor, a nurse practitioner, a physician assistant, a nurse, or anyone else you would see for health care.

In the last 6 months, did you try to make an appointment with a doctor or other health provider at this clinic?

1  Yes

0  No GO TO Q.5

Q4. (If Yes) In the last 6 months, how often did you get an appointment at this clinic as soon as you wanted?

MARK (X) ONE ANSWER

1  Never

2  Sometimes

3  Usually

4  Always

Q5. In the last 6 months, how often were you taken to the exam room within 15 minutes of your arrival at the clinic?

MARK (X) ONE ANSWER

1  Never

2  Sometimes

3  Usually

4  Always

Q.6 In the last 6 months, how many times did you go to this clinic to get care for yourself?

MARK (X) ONE ANSWER

1  1 time

2  2 times

3  3 times

4  4 times

5  5 to 9 times

6  10 times or more

Q.7. In the last 6 months, how often did doctors or other health providers at this clinic listen carefully to you?

MARK (X) ONE ANSWER

1  Never

2  Sometimes

3  Usually

4  Always

Q8. In the last 6 months, how often did doctors or other health providers at this clinic explain things in a way you could understand?

MARK (X) ONE ANSWER

1  Never

2  Sometimes

3  Usually

4  Always

Q9. In the last 6 months, how often did doctors or other health providers at this clinic spend enough time with you?

MARK (X) ONE ANSWER

1  Never

2  Sometimes

3  Usually

4  Always

Q10. Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your health care at this clinic in the last 6 months?

MARK (X) ONE ANSWER

0  0 Worst health care possible

1  1

2  2

3  3

4  4

5  5

6  6

7  7

8  8

9  9

10  10 Best health care possible

PRESCRIPTION MEDICINES

The next questions are about your prescription medications. Do not include prescriptions ordered or purchased for children or other family members.

Q.11. In the past 6 months, was there any time when you needed prescription medicines but couldn’t get them because you couldn’t afford them?

1  YES

0  NO

Q.12. In the last 6 months, did you fill any new prescription medicines or refill a prescription?

Include prescriptions filled at this clinic or any other place.

1  YES

0  NO GO TO Q. 17, PAGE 4

Q.13. (If Yes) In the last 6 months, how many times did you fill or refill prescription medicines?

MARK (X) ONE ANSWER

1  1 time

2  2 times

3  3 times

4  4 times

5  5 to 9 times

6  10 times or more

Q14. In the past 6 months about how much did you pay with your own money for prescription medicines?

0  None

1  $1 to $25

2  $26 to $50

3  $51 to $100

4  $101 to $200,

5  $201 to $500,

6  More than $500?

Q15. The next two questions ask about the past 4 weeks instead of the past 6 months.

In the past 4 weeks, was there any time when you skipped taking a prescription medicine that you should have taken?

1  YES

0  NO

Q16. In the past 4 weeks, was there any time when you took less of your prescription medicine than you were supposed to? For example, you took only half of a pill when you were supposed to take a full pill.

1  YES

0  NO

PRESCRIPTION MEDICINES FROM THIS CLINIC

Q17. The next questions are about prescription medicines you got from this clinic.

In the last 6 months, did you fill any new prescription medicine or refill a prescription at this clinic?

1  YES

0  NO IF NO, GO TO Q. 27, PAGE 6

Q18. (If Yes) In the last 6 months, how many times did you fill or refill prescription medicines at this clinic?

1  1 time

2  2 times

3  3 times

4  4 times

5  5 to 9 times

6  10 times or more

Q19. In the last 6 months, how much of a problem, if any, was it to fill your prescription medicines at this clinic?

1  A big problem

2  A small problem

3  Not a problem

Q20. Is the clinic’s pharmacy open when it is convenient to get your prescriptions?

1  YES

0  NO

Q21. About how long does it take to get to the clinic’s pharmacy from your home?

1  Less than 15 minutes

2  15 to 30 minutes

3  More than 30 to 60 minutes

4  More than 60 minutes

Q22. About how long do you usually have to wait in line to get your prescriptions from the clinic’s pharmacy?

1  Just a few minutes

2  More than a few minutes but less than 15 minutes

3  More than 15 minutes

Q23. In the last 6 months, how often did pharmacists or other health providers at this clinic explain how to take your prescription medications in a way you could understand?

MARK (X) ONE ANSWER

1  Never

2  Sometimes

3  Usually

4  Always

Q24. In the last 6 months, how often did health providers at this clinic give you free samples of medications?

MARK (X) ONE ANSWER

1  Never

2  Sometimes

3  Usually

4  Always

Q25. In the last six months, did you talk to a pharmacist or other health provider at this clinic about side effects from one of your prescription medicines?

1  YES

0  NO GO TO Q26

A. IF YES: How helpful was the pharmacist or other health provider who talked to you about the side effects from your prescription medicine?

1  Very helpful

2  Somewhat helpful

3  Not very helpful

Q26. We want to know your rating of the services you have received from the pharmacy at this clinic.

Using any number from 0 to 10, where 0 is the worst service possible and 10 is the best service possible, what number would you use to rate the services you have received from the clinic’s pharmacy in the last 6 months?

MARK (X) ONE ANSWER

0  0 Worst service possible

1  1

2  2

3  3

4  4

5  5

6  6

7  7

8  8

9  9

10  10 Best service possible

ABOUT YOU

Q27. What kind of health insurance or health care coverage do you have?

MARK (X) FOR THE TYPE OF HEALTH INSURANCE YOU HAVE. IF YOU HAVE NO HEALTH INSURANCE, CHECK “NO COVERAGE OF ANY TYPE”

1  Private health insurance through your employer or that you bought yourself

2  Medicare (the government program for people 65 and older and people with certain disabilities)

3  Medicaid (the government assistance program that pays for health care for people in need)

4  Military health care (TRICARE/VA/CHAMP-VA)

5  Indian health service

6  Some other kind of coverage

[please describe]

7  No coverage of any type

Q28. In general, how would you rate your overall health now?

MARK (X) ONE ANSWER

1  Excellent

2  Very good

3  Good

4  Fair

5  Poor

Q29. Walking About

MARK (X) NEXT TO THE STATEMENT THAT BEST DESCRIBES YOUR OWN HEALTH TODAY

1  I have no problems in walking about

2  I have some problems in walking about

3  I am confined to bed

Q30. Washing or Dressing

MARK (X) NEXT TO THE STATEMENT THAT BEST DESCRIBES YOUR OWN HEALTH TODAY

1  I have no problems with washing or dressing myself

2  I have some problems with washing or dressing myself

3  I am unable to wash or dress myself

Q31. Usual Activities ( such as work, study, housework, family, or leisure activities)

MARK (X) NEXT TO THE STATEMENT THAT BEST DESCRIBES YOUR OWN HEALTH TODAY

1  I have no problems with performing my usual

activities

2  I have some problems with performing my

usual activities

3  I am unable to perform my usual activities

Q32. Pain or Discomfort

MARK (X) NEXT TO THE STATEMENT THAT BEST DESCRIBES YOUR OWN HEALTH TODAY

1  I have no pain or discomfort

2  I have moderate pain or discomfort

3  I have extreme pain or discomfort

Q33. Anxiety/Depression

MARK (X) NEXT TO THE STATEMENT THAT BEST DESCRIBES YOUR OWN HEALTH TODAY

1  I am not anxious or depressed

2  I am moderately anxious or depressed

3  I am extremely anxious or depressed

Q34. What is your age now?

MARK (X) ONE ANSWER

1  18 to 24

2  25 to 34

3  35 to 44

4  45 to 54

5  55 to 64

6  65 to 74

7  75 or older

Q35. Are you male or female?

MARK (X) ONE ANSWER

1  Male

2  Female

Q36. What is the highest grade or level of school that you have completed?

MARK (X) ONE ANSWER

1  8th grade or less

2  Some high school, but did not graduate

3  High school graduate or GED

4  Some college or 2-year degree

5  4-year college graduate

6  More than 4-year college degree

Q37. Are you of Hispanic or Latino origin or descent?

MARK (X) ONE ANSWER

1  Yes, Hispanic or Latino

2  No, not Hispanic or Latino

Q38. What is your race?

PLEASE MARK (X) ONE OR MORE ANSWERS

1  White

2  Black or African-American

3  Asian

4  Native Hawaiian or other Pacific Islander

5  American Indian or Alaska Native

6  Other

Q39. What language do you mainly speak at home?

MARK (X) ONE ANSWER

1  English

2  Spanish

3  Some other language

(PLEASE DESCRIBE BELOW)

Q40. Did someone help you complete this survey?

MARK (x) one answer

1  Yes

0  No

MPR DOCUMENTATION PURPOSES ONLY:

/home/ec2-user/sec/disk/omb/icr/200701-0915-004/doc/1551901

(REV—5/10/05) 2/6/2021 8:24 AM

Jen revised for Richard Strouse

NHSC – 6126-072