4 Built-Peds

B

OMB Number: 0925-0458
Expiration Date: 06/30/2007
Please use the enclosed envelope and mail
the completed survey to:
NRC+Picker
Survey Processing Center
PO BOX 82660
Lincoln, NE 68501-2660
1-800-733-6714
Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or
sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705
Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0458). Do not return the completed form to this address.

We are asking about your perceptions about our hospitaI's physicaI space incIuding the design, architecture, Iayout, forms, surfaces,
furnishings, artwork, and outdoor spaces.
PIease fiII in the bubbIe that best describes you and your chiId's experiences with the hospitaI environment during your chiId's most recent
CIinicaI Center stay.
OnIy the parent or guardian of the patient who was in the hospitaI shouId fiII out this questionnaire. As you answer, pIease think ONLY
about your chiId's hospitaI stay on March 3, 2005.
These questions ask about getting to the hospital, parking, and finding the hospital entrance.
1. For your chiId's most recent stay, how did you and your chiId get to the hospitaI?24226
1
E
2
E

3
E
4
E

I drove us myself
Family member or friend drove us

We took public transportation
We were brought by ambulance

5
E

We took a taxi cab

2. Were there signs directing you to the parking garage or drop off area?24227
1
E

Yes

2
E

No (Go to #4)

3. Were these signs heIpfuI?24228
1
E

Not at all

2
E

Somewhat

-89
E

3
E

Don't know (Go to #4)

For the most part

4
E

Definitely

4. Did you park a car in the hospitaI's garage?24229
1
E

Yes

2
E

No

5. Were there enough parking spaces at the hospitaI?24230
1
E

Yes

2
E

No

6. Did you need a handicapped-accessibIe parking space?24231
1
E

Yes

2
E

No (Go to #8)

7. Were there enough handicapped-accessibIe parking spaces near the hospitaI entrance?24232
1
E

Yes

2
E

No

8. Were there signs directing you to the entrance of the hospitaI?24233
1
E

Yes

2
E

No (Go to #10)

9. Were these signs heIpfuI?24234

B

1
E

Not at all

2
E

Somewhat

-89
E

3
E

Don't know (Go to #10)

For the most part

*001MMD1G*

4
E

Definitely

*001MMD1G*

0075973

*00*
B

B

10. Was there a pIace near the hospitaI entrance for you to wait for someone who dropped you and your chiId off or was picking you up?24235
1
E

2
E

Yes

-E
89 Don't know

No

These questions ask about registration and finding your way around inside the hospital.
11. Did you enter the hospitaI through the parking garage or through the main Iobby entrance?24236
1
E

2
E

Main Lobby

3
E

Parking Garage

-E
89 Don't remember

Neither

12. Once you entered the hospitaI, was it easy to find someone to provide you with information or directions?24237
1
E

2
E

Not at all

3
E

Somewhat

4
E

For the most part

Definitely

13. When your chiId first came to the CIinicaI Center, did the buiIding make your chiId feeI comfortabIe?24238
1
E

2
E

Not at all

3
E

Somewhat

14. Were the peopIe at the information desks heIpfuI?24239
-89
E

1
E

Doesn't apply

2
E

Not at all

Somewhat

15. Were the peopIe at the information desks courteous?24240
-89
E

1
E

Doesn't apply

2
E

Not at all

4
E

For the most part

Somewhat

Definitely

3
E

For the most part

4
E

Definitely

3
E

For the most part

4
E

Definitely

16. Once you entered the hospitaI, was it easy to find the admissions area?24241
1
E

2
E

Not at all

Somewhat

3
E

4
E

For the most part

Definitely

17. Was there a pIace in the admissions area to taIk privateIy with staff?24242
1
E

2
E

Yes

No

-E
89 Did not talk with the admissions staff

18. If you used signs, maps, or directions that showed you where to find departments or areas, did you find them heIpfuI?24243
-E
89 Didn't use

1
E

Not at all

2
E

3
E

Somewhat

For the most part

4
E

Definitely

3
E

For the most part

19. Were there coIorfuI or interesting signs and pictures in the chiIdren's units?24244
1
E

2
E

Not at all

Somewhat

3
E

For the most part

4
E

Definitely

The following questions are about your child's hospital room.
20. Was the artwork in your chiId's room pIeasant to Iook at?24245
-89
E

1
E

My child's room didn't have artwork

Not at all

2
E

Somewhat

4
E

Definitely

21. Did your chiId want to put things in his or her room to make it more home-Iike such as pictures or toys?24246
1
E
2
E

3
E
4
E

Yes
No (Go to #23)

My child was too young (Go to #23)
Not permitted to have personal items like that in room (Go to #23)

22. Was there enough space, such as sheIves and counters, on which to pIace items to make your chiId's room more home-Iike?24247
1
E

2
E

Not at all

Somewhat

3
E

For the most part

4
E

Definitely

23. Did you and your chiId have enough space for cIothes and other personaI beIongings?24248
1
E

2
E

Not at all

Somewhat

3
E

For the most part

4
E

Definitely

24. Did your chiId bring any vaIuabIe beIongings with him or her to the hospitaI?24249
1
E

2
E

Yes

No (Go to #26)

25. WhiIe your chiId was in the hospitaI, did you think your chiId's vaIuabIe beIongings were safe?24250
1
E

2
E

Not at all

Somewhat

3
E

For the most part

4
E

Definitely

26. How often was the temperature of your chiId's room just right?24251

B

1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

*001MMD2H*

*001MMD2H*

0075973

*00*
B

B

27. Was it easy for you or your chiId to controI the room temperature?24252
1
E

Never

2
E

Sometimes

3
E

4
E

Usually

Always

28. Was it easy for you or your chiId to controI the room's Iighting?24253
1
E

Never

2
E

Sometimes

3
E

4
E

Usually

Always

29. Did your chiId have a roommate?24254
1
E

2
E

Yes

No (Go to #31)

30. If your chiId had a roommate, how often did he or she hear noise from the other patient in the room?24255
1
E

Never

2
E

Sometimes

3
E

4
E

Usually

Always

31. How often did you or your chiId hear noise from the unit outside of his or her room?24256
1
E

Never (Go to #33)

2
E

Sometimes

3
E

4
E

Usually

Always

32. If your chiId heard noise outside his or her room did this noise affect his or her abiIity to rest/sIeep?24257
1
E

Never

2
E

Sometimes

3
E

4
E

Usually

Always

33. How often was your chiId's room kept as cIean as it shouId have been?24258
1
E

Never

2
E

Sometimes

3
E

4
E

Usually

Always

34. Did your chiId have a teIephone in his or her room?24259
1
E

2
E

Yes

No (Go to #36)

35. Was it easy for your chiId to reach the teIephone from his or her bed?24261
-89
E

36. Was it easy for your chiId to use the caII button?24262
-89
E

1
E

Never

Sometimes

3
E

My child did not use the telephone in his or her room
1
E

Didn't use the call button

Never

2
E

2
E

3
E

Sometimes

Usually

4
E

Usually

4
E

Always

Always

37. Was there enough space in your chiId's room for hospitaI staff to get around?24263
1
E

Never

2
E

Sometimes

3
E

4
E

Usually

Always

38. During your chiId's hospitaI stay, did he or she get out of bed?24264
1
E

2
E

Yes

No (Go to #42)

39. Were there things such as heavy doors, narrow doorways, or sIippery fIoors that made it hard for your chiId to get into the bathroom?24265
1
E

Never

2
E

Sometimes

3
E

4
E

Usually

Always

40. Were there enough features avaiIabIe, such as handraiIs, so that your chiId feIt safe and secure when he or she was out of bed?24266
1
E

Never

2
E

Sometimes

3
E

4
E

Usually

Always

41. Was the shower in your chiId's room convenient to use?24267
-E
89 Didn't have a shower

1
E

2
E

Not at all

Somewhat

3
E

4
E

For the most part

Definitely

42. Did your chiId have a window in his or her room?24269
1
E

2
E

Yes

No (Go to #47)

43. Did your chiId want to adjust the window bIinds/curtains in his or her room?24270
1
E

2
E

Yes

3
E

No (Go to #45)

My child was too young to adjust the window blinds/curtains (Go to #45)

44. Was it easy for your chiId to adjust the window bIinds/curtains in his or her room?24271
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

45. Was the window Iocated so that your chiId couId see the outdoors whiIe Iying in bed?24272

B

1
E

Yes

2
E

No

*001MMD3I*

*001MMD3I*

0075973

*00*
B

B

46. Did your chiId have a pIeasant view of the outdoors from the window in his or her room?24273
1
E

2
E

Yes

No

47. Was your chiId abIe to access the Internet and emaiI from his or her hospitaI room?24274
1
E

2
E

Yes

-88
E

No (Go to #49)

-E
89 Doesn't apply (Go to #49)

Don't know (Go to #49)

48. Was it easy for your chiId to access the Internet or emaiI from his or her room?24275
1
E

2
E

Never

3
E

Sometimes

Usually

4
E

Always

49. OveraII, how wouId you rate the comfort of your chiId's hospitaI room on a scaIe from 0 to 10, where 0 is "the worst" and 10 is "the best"?24276
0 Worst
0
E

1

2

1
E

3

2
E

4

3
E

5

4
E

6

5
E

7

6
E

7
E

8

9

8
E

9
E

10 Best
10
E

The next few questions ask about you and your child's privacy.
50. Do you feeI your chiId had enough privacy in his or her room?24277
1
E

2
E

Not at all

Somewhat

3
E

4
E

For the most part

Definitely

51. Were there pIaces on your chiId's unit for him or her to go to be aIone?24278
1
E
2
E

-87
E
-88
E

Yes
No

-89
E

Don't know
My child was too sick to go anywhere

My child was too young to go anywhere on his or her own

52. Were there private areas where you couId taIk with staff about things such as your chiId's iIIness and treatment?24279
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

Now we would like to find out about your child's experience in getting around outside of his or her room.
53. During your chiId's hospitaI stay, did he or she go outside of his or her room?24280
1
E

2
E

Yes

No (Go to #62)

54. Were the haIIways cIear of things such as furniture, beds or carts?24281
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

55. Were there bumps or grooves in the fIoor that made it hard for your chiId to move about?24282
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

56. Were there features avaiIabIe, such as handraiIs or support, so that your chiId feIt safe and secure when he or she was waIking outside his or
her room?24283
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

57. Were there enough pIaces cIose by but away from your chiId's unit where he or she couId sit and reIax with his or her famiIy or by himseIf or
herseIf?24284
-89
E

Don't know

1
E

2
E

Not at all

Somewhat

3
E

For the most part

4
E

Definitely

58. Were there enough benches or chairs avaiIabIe for your chiId to rest in haIIways whiIe he or she was moving about the hospitaI?24285
-89
E

Don't know

1
E

Never

2
E

3
E

Sometimes

Usually

4
E

Always

59. Was there a comfortabIe pIace for your chiId to go that was right for his or her age?24286
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

60. Was there furniture avaiIabIe for your chiId that was right for his or her age?24287
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

61. Were there things for your chiId to do (games, toys) that were right for his or her age?24288

B

1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

*001MMD4J*

*001MMD4J*

0075973

*00*
B

B

62. Were there pubIic teIephones on your chiId's unit?24289
1
E

2
E

Yes

-E
89 Don't know

No

63. Was your chiId abIe to go outside the hospitaI during his or her stay?24290
1
E

2
E

Yes

No (Go to #65)

64. If yes, were there pIeasant green spaces near (just outside) the hospitaI where your chiId couId sit and reIax?24291
1
E

2
E

Not at all

Somewhat

3
E

4
E

For the most part

Definitely

The following questions are about places for visitors.
65. WhiIe your chiId was in the hospitaI, did he or she have visitors?24292
1
E

2
E

Yes

No (Go to #81)

66. Were pubIic restrooms avaiIabIe to your chiId's visitors?24293
1
E

2
E

Yes

-89
E

No

Don't know

67. Was your chiId's room Iarge enough for his or her visitors?24294
1
E

2
E

Never

Sometimes

3
E

Usually

4
E

Always

68. Was there enough space in the visiting/waiting area for your chiId's visitors to be comfortabIe?24295
-89
E

1
E

No visiting/waiting area (Go to #71)

2
E

Never

Sometimes

3
E

Usually

4
E

Always

69. Was there entertainment such as music, reading materiaIs, TV, or artwork, in the visiting/waiting area?24296
-89
E

1
E

Don't know

2
E

Not at all

Somewhat

3
E

For the most part

4
E

Definitely

70. Was there enough privacy for your chiId's famiIy or visitors in the visiting/waiting area?24297
-89
E

1
E

Don't know

2
E

Not at all

Somewhat

3
E

For the most part

4
E

Definitely

71. Was there a separate pIace for chiIdren to pIay whiIe visiting/waiting?24298
1
E

2
E

Yes

-89
E

No

Don't know

72. Did any of your chiId's famiIy members or friends stay overnight?24299
1
E

2
E

Yes

No (Go to #74)

73. Were the sIeeping areas for your chiId's famiIy members or friends comfortabIe?24300
-89
E

Don't know

1
E

2
E

Not at all

Somewhat

3
E

For the most part

4
E

Definitely

74. Did you feeI comfortabIe staying with your chiId during his or her stay?24301
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

75. If you stayed with your chiId during his or her stay, did you have enough privacy to attend to your personaI needs?24302
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

76. Did you feeI comfortabIe Ieaving your chiId whiIe you sIept or attended to personaI needs?24303
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

77. Were the restrooms set up in a manner that wouId aIIow you to meet your and your famiIy's personaI needs?24304
1
E

2
E

Not at all

Somewhat

3
E

For the most part

4
E

Definitely

78. Was there a pIace where famiIy members couId reIax with each other?24305
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

79. In generaI, did you and your chiId find the chiIdren's areas of the hospitaI to be chiId and famiIy-friendIy?24306

B

1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

*001MMD5K*

*001MMD5K*

0075973

*00*
B

B

80. OveraII, how wouId you rate the accommodations for your chiId's famiIy and visitors on a scaIe from 0 to 10, where 0 is "the worst" and 10 is
"the best"?24307
0 Worst
0
E

1

2

1
E

3

2
E

3
E

4

5

4
E

6

5
E

7

6
E

8

7
E

9

8
E

10 Best
10
E

9
E

We are interested in finding out whether people who used equipment during their hospital stay had enough space to get around.
81. WhiIe your chiId was in the hospitaI, did he or she use any of the foIIowing equipment to get around? (Mark aII that appIy)24308
1
F

2
F

Wheelchair

Walker

3
F

Crutches

4
F

IV pole

5
F

Other

-89
F

Didn't use any equipment (Go to #85)

82. Was there enough space in the bathroom(s) to use equipment?24309
1
E

Yes

2
E

No

83. Was there enough space in the eIevators to use equipment?24310
1
E

Yes

2
E

No

84. Was there enough space in your chiId's room to move around with equipment?24311
1
E

Yes

2
E

No

These questions ask about your general opinions of the hospital environment.
How wouId you rate the importance of each of the foIIowing?
Not At All Somewhat
Very
Important Important Important Important
1
2
3
4
E
E
E
E

85. Having a private room24312
86. ControIIing the room temperature24313

1
E

2
E

3
E

4
E

87. ControIIing the indoor room Iighting24314

1
E

2
E

3
E

4
E

88. Having music (e.g., radio, tape pIayer, CD pIayer)24315

1
E

2
E

3
E

4
E

89. Having a teIevision and/or VCR24316

1
E

2
E

3
E

4
E

90. Having a private shower24317

1
E

2
E

3
E

4
E

91. Being abIe to find your way around24318

1
E

2
E

3
E

4
E

92. Having emaiI and Internet access24319

1
E

2
E

3
E

4
E

93. Access to areas in the hospitaI to sit or to waIk around24320

1
E

2
E

3
E

4
E

94. Access to outside green areas to sit or waIk24321

1
E

2
E

3
E

4
E

B

95. How wouId you rate the quaIity of the food service in the CIinicaI Center?1382
a. Courtesy of the person who took your chiId's food order24322

Poor
1
E

Fair
2
E

Good
3
E

Excellent
4
E

b. Variety of menu items24323

1
E

2
E

3
E

4
E

c. Received food in a timeIy manner (within 45 min. of order)24324

1
E

2
E

3
E

4
E

d. Temperature of the food24325

1
E

2
E

3
E

4
E

*001MMD6L*

*001MMD6L*

0075973

*00*
B

B

95. How wouId you rate the quaIity of the food service in the CIinicaI Center?1382

Poor
1
E

e. OveraII quaIity of the food24326

Fair
2
E

Good
3
E

Excellent
4
E

96. Regarding the HOSPITAL ENVIRONMENT, how wouId you rate the hospitaI environment on a scaIe from 0 to 10, where 0 is "the worst
environment" and 10 is "the best environment"?24327
0 Worst
0
E

1

2

1
E

2
E

3

4

3
E

5

4
E

5
E

6

7

6
E

7
E

8

8
E

9

9
E

10 Best
10
E

97. On a scaIe of 0 to 10 where 0 is not at aII important and 10 is extremeIy important, how wouId you rate the importance of this hospitaI's
environment to your chiId's OVERALL SENSE OF WELL-BEING?24328
0 Not at all
important
0
E

1
1
E

2
2
E

3
3
E

4
4
E

5
5
E

6
6
E

7
7
E

8
8
E

9
9
E

10 Extremely
important
10
E

98. On a scaIe of 0 to 10 where 0 is not at aII important and 10 is extremeIy important, how wouId you rate the importance of this hospitaI's
environment to your chiId's famiIy or visitors' OVERALL SENSE OF WELL-BEING?24329
0 Not at all
important
0
E

1
1
E

2
2
E

3
3
E

4
4
E

5
5
E

6
6
E

7
7
E

8
8
E

9
9
E

10 Extremely
important
10
E

99. Is there anything eIse you wouId Iike to teII us about how the HOSPITAL ENVIRONMENT infIuenced you or your chiId's experience during
your chiId's hospitaI stay?

Now we would like to ask you some questions about other aspects of your child's hospital experience.
100. Was it easy for you to find someone on the hospitaI staff to taIk to about your concerns?24330
1
E

Yes, defintiely

2
E

Yes, somewhat

3
E

No

-89
E

Didn't want to talk/no concerns

101. Did you or your famiIy have enough opportunity to taIk to your chiId's doctor?24331
1
E

Yes, definitely

2
E

Yes, somewhat

3
E

No

-89
E

Didn't want or need to talk

102. Did a doctor or nurse expIain the resuIts of tests in a way you couId understand?24332
1
E

2
E

Yes, completely

3
E

Yes, somewhat

No

-89
E

No tests were done

103. Sometimes in the hospitaI, one doctor or nurse wiII say one thing and another wiII say something quite different. Did this happen during
your chiId's hospitaI stay?24333
1
E

2
E

Yes, always

Yes, sometimes

3
E

No

104. Did you feeI Iike your chiId was treated with respect and dignity whiIe he or she was in the hospitaI?24334
1
E

2
E

Yes, always

Yes, sometimes

3
E

No

105. Was your chiId ever in any pain?24335
1
E

Yes

2
E

No (Go to #108)

106. Do you think that the hospitaI staff did everything they couId to heIp controI your chiId's pain?24336

B

1
E

Yes, definitely

2
E

Yes, somewhat

3
E

No

*001MMD7M*

*001MMD7M*

0075973

*00*
B

B

107. OveraII, how much pain medicine did your chiId get?24337
1
E

2
E

Not enough

3
E

Right amount

Too much

108. Did someone on the hospitaI staff expIain the purpose of the medicines your chiId was to take at home in a way you couId understand?24338
1
E
2
E

Yes, completely
Yes, somewhat

3
E
-88
E

-89
E

No
Didn't need explanation

My child didn't receive medicine to take home

109. Did they teII you when your chiId couId resume his or her usuaI activities, such as eating, bathing, pIaying sports, or returning to schooI?24339
1
E

Yes, completely

2
E

Yes, somewhat

3
E

No

110. Did the doctors and nurses give you or your famiIy aII the information you or they needed to heIp your chiId recover?24340
1
E

2
E

Yes, definitely

3
E

Yes, somewhat

No

-89
E

Didn't want or need information

111. Upon your chiId's discharge from the hospitaI were you provided with adequate information regarding your chiId's condition and care?24341
1
E

Yes, completely

2
E

Yes, somewhat

3
E

No

112. OveraII, how wouId you rate the care your chiId received at the hospitaI?9118
1
E

2
E

Poor

3
E

Fair

Good

4
E

5
E

Very Good

Excellent

And finally, we would like to get some information on your child's health and background.
113. In generaI, how wouId you rate your chiId's heaIth?24342
1
E

2
E

Poor

3
E

Fair

Good

4
E

5
E

Very Good

114. How many nights did your chiId spend at the hospitaI?24343
1

1
E

2

2
E

3

3
E

4

4
E

Excellent

5

115. Which of the foIIowing best describes your chiId's ethnic or raciaI background?24268
1
E
2
E
3
E

Hispanic or Latino
Not Hispanic or Latino
American Indian or Alaska Native

4
E
5
E
6
E

6-9

5
E

Asian
Black or African American
Native Hawaiian or Other Pacific Islander

6
E

7
E

10-15
7
E

More than 15
8
E

White

Thank you for taking the time to complete this questionnaire! Your answers are greatly appreciated.

B

© NRC+Picker, All Rights Reserved

*001MMD8N*

*001MMD8N*

0075973

*00*
B