Form 3 Built-Adults

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 your experiences with the hospitaI environment during your most recent CIinicaI Center stay.
OnIy the patient who was in the hospitaI shouId fiII out this questionnaire. As you answer, pIease think ONLY about your hospitaI stay on
March 3, 2005.
These questions ask about getting to the hospital, parking, and finding the hospital entrance.
1. For your most recent stay, how did you get to the hospitaI?23862
1
E
2
E

3
E
4
E

I drove myself
Family member or friend drove me

I took public transportation
I was brought by ambulance

5
E

I took a taxi cab

2. Were there signs directing you to the parking garage or drop off area?23863
1
E

Yes

2
E

No (Go to #4)

3. Were these signs heIpfuI?23864
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?23865
1
E

Yes

2
E

No

5. Were there enough parking spaces at the hospitaI?13860
1
E

Yes

2
E

No

6. Did you need a handicapped-accessibIe parking space?13862
1
E

Yes

2
E

No (Go to #8)

7. Were there enough handicapped-accessibIe parking spaces near the hospitaI entrance?23866
1
E

Yes

2
E

No

8. Were there signs directing you to the entrance of the hospitaI?23867
1
E

Yes

2
E

No (Go to #10)

9. Were these signs heIpfuI?23868

B

1
E

Not at all

2
E

Somewhat

-89
E

3
E

Don't know (Go to #10)

For the most part

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4
E

Definitely

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10. Was there a pIace near the hospitaI entrance for you to wait for someone who dropped you off or was picking you up?23869
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?23870
1
E

2
E

Main Lobby

3
E

Parking Garage

-89
E

Neither

Don't remember

12. Once you entered the hospitaI, was it easy to find someone to provide you with information or directions?23871
1
E

2
E

Not at all

3
E

Somewhat

13. Were the peopIe at the information desks heIpfuI?23872
-89
E

1
E

Doesn't apply

2
E

Not at all

Somewhat

14. Were the peopIe at the information desks courteous?23873
-E
89 Doesn't apply

1
E

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

15. Once you entered the hospitaI, was it easy to find the admissions area?23874
1
E

2
E

Not at all

Somewhat

3
E

4
E

For the most part

Definitely

16. Was there a pIace in the admissions area to taIk privateIy with staff?23875
1
E

2
E

Yes

No

-E
89 Did not talk with the admissions staff

17. If you used signs, maps, or directions that showed you where to find departments or areas, did you find them heIpfuI?23876
-89
E

1
E

Didn't use

Not at all

2
E

3
E

Somewhat

4
E

For the most part

Definitely

The following questions are about your hospital room.
18. Was the artwork in your room pIeasant to Iook at?23885
-89
E

My room didn't have artwork

1
E

Not at all

2
E

Somewhat

3
E

For the most part

4
E

Definitely

19. Did you want to put things in your room to make it more home-Iike such as pictures, pIants, or fIowers?23877
1
E

2
E

Yes

3
E

No (Go to #21)

Not permitted to have personal items like that in my room (Go to #21)

20. Was there enough space, such as sheIves and counters, on which to pIace items to make your room more home-Iike?23878
1
E

2
E

Not at all

Somewhat

3
E

For the most part

4
E

Definitely

21. Did you have enough space for your cIothes and other personaI beIongings?23879
1
E

2
E

Not at all

Somewhat

3
E

For the most part

4
E

Definitely

22. Did you bring any vaIuabIe beIongings with you to the hospitaI?13884
1
E

2
E

Yes

No (Go to #24)

23. WhiIe you were in the hospitaI, did you think your vaIuabIe beIongings were safe?23880
1
E

2
E

Not at all

Somewhat

3
E

For the most part

24. How often was the room temperature just right?24067
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

4
E

Definitely

Always

25. Was it easy for you to controI the room temperature?24068

B

1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

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26. Was it easy for you to controI the room's Iighting?24069
1
E

Never

2
E

Sometimes

3
E

4
E

Usually

Always

27. Did you have a roommate?23881
1
E

2
E

Yes

No (Go to #29)

28. If you had a roommate, how often did you hear noise from the other patient in your room?23882
1
E

Never

2
E

Sometimes

3
E

4
E

Usually

Always

29. How often did you hear noise from the unit outside of your room?23883
1
E

Never

2
E

Sometimes

3
E

4
E

Usually

Always

30. If you heard noise outside your room did this noise affect your abiIity to rest/sIeep?23884
1
E

Never

2
E

Sometimes

3
E

4
E

Usually

Always

31. How often was your room kept as cIean as it shouId have been?23886
1
E

Never

2
E

Sometimes

3
E

4
E

Usually

Always

32. Did you have a teIephone in your room?13892
1
E

2
E

Yes

No (Go to #34)

33. Was it easy for you to reach the teIephone from your bed?23887
1
E

Never

2
E

Sometimes

3
E

34. Was it easy for you to use the caII button?23888
-89
E

1
E

Didn't use the call button

4
E

Usually

Never

2
E

Always

Sometimes

3
E

Usually

4
E

Always

35. Was there enough space in your room for hospitaI staff to get around?23889
1
E

Never

2
E

Sometimes

3
E

4
E

Usually

Always

36. During your hospitaI stay, did you get out of bed?13896
1
E

2
E

Yes

No (Go to #40)

37. Were there things such as heavy doors, narrow doorways, or sIippery fIoors that made it hard for you to get into the bathroom?23890
1
E

Never

2
E

Sometimes

3
E

4
E

Usually

Always

38. Were there enough features avaiIabIe, such as handraiIs, so that you feIt safe and secure when you were out of bed?23891
1
E

Never

2
E

Sometimes

3
E

4
E

Usually

Always

39. Was the shower in your room convenient to use?23892
-89
E

Didn't have a shower

1
E

Not at all

2
E

Somewhat

3
E

For the most part

4
E

Definitely

40. Did you have a window in your room?13900
1
E

2
E

Yes

No (Go to #45)

41. Did you want to adjust the window bIinds/curtains in your room?13901
1
E

2
E

Yes

No (Go to #43)

42. Was it easy for you to adjust the window bIinds/curtains in your room?23893
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

43. Was the window Iocated so that you couId see the outdoors whiIe Iying in bed?13903

B

1
E

Yes

2
E

No

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44. Did you have a pIeasant view of the outdoors from the window in your room?13904
1
E

2
E

Yes

No

45. Were you abIe to access the Internet and emaiI from your hospitaI room?23894
1
E

2
E

Yes

-88
E

No (Go to #47)

-E
89 Doesn't apply (Go to #47)

Don't know (Go to #47)

46. Was it easy for you to access the Internet or emaiI from your room?23895
1
E

2
E

Never

3
E

Sometimes

Usually

4
E

Always

47. OveraII, how wouId you rate the comfort of your hospitaI room on a scaIe from 0 to 10, where 0 is "the worst" and 10 is "the best"?23896
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

8
E

9

9
E

10 Best
10
E

The next few questions ask about your privacy.
48. Do you feeI you had enough privacy in your room?23897
1
E

2
E

Not at all

Somewhat

3
E

4
E

For the most part

Definitely

49. Were there pIaces on your unit for you to go to be aIone?23898
1
E

2
E

Yes

-E
88 Don't know

No

-E
89 I was too sick to go anywhere

50. Were there private areas where you couId taIk with staff about things such as your iIIness and treatment?23899
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

Now we would like to find out about your experience in getting around outside of your room.
51. During your hospitaI stay, did you go outside of your room?13909
1
E

2
E

Yes

No (Go to #57)

52. Were the haIIways cIear of things such as furniture, beds or carts?23900
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

53. Were there bumps or grooves in the fIoor that made it hard for you to move about?23901
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

54. Were there features avaiIabIe, such as handraiIs or support, so that you feIt safe and secure when you were waIking outside your room?23902
1
E

Never

2
E

Sometimes

3
E

Usually

4
E

Always

55. Were there enough pIaces cIose by but away from your unit where you couId sit and reIax with your famiIy or by yourseIf?23903
-89
E

1
E

Don't know

2
E

Not at all

Somewhat

3
E

For the most part

4
E

Definitely

56. Were there enough benches or chairs avaiIabIe for you to rest in haIIways whiIe you were moving about the hospitaI?23904
-89
E

1
E

Don't know

Never

2
E

Sometimes

3
E

Usually

4
E

Always

57. Were there pubIic teIephones on your unit?24070
1
E

Yes

2
E

No

-89
E

Don't know

58. Were you abIe to go outside the hospitaI during your stay?23905

B

1
E

Yes

2
E

No (Go to #60)

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59. If yes, were there pIeasant green spaces near (just outside) the hospitaI where you couId sit and reIax?23906
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.
60. WhiIe you were in the hospitaI, did you have visitors?13915
1
E

2
E

Yes

No (Go to #70)

61. Were pubIic restrooms avaiIabIe to your visitors?24071
1
E

2
E

Yes

-89
E

No

Don't know

62. Was your room Iarge enough for your visitors?23907
1
E

Never

2
E

3
E

Sometimes

Usually

4
E

Always

63. Was there enough space in the visiting/waiting area for your visitors to be comfortabIe?23908
-89
E

1
E

No visiting/waiting area (Go to #66)

2
E

Never

Sometimes

3
E

4
E

Usually

Always

64. Was there entertainment such as music, reading materiaIs, TV, or artwork, in the visiting/waiting area?23909
-89
E

1
E

Don't know

Not at all

2
E

3
E

Somewhat

4
E

For the most part

Definitely

65. Was there enough privacy for your famiIy or visitors in the visiting/waiting area?23910
-89
E

1
E

Don't know

Not at all

2
E

3
E

Somewhat

For the most part

4
E

Definitely

4
E

Definitely

66. Was there a separate pIace for chiIdren to pIay whiIe visiting/waiting?24072
1
E

2
E

Yes

-E
89 Don't know

No

67. Did any of your famiIy members or friends stay overnight?13923
1
E

2
E

Yes

No (Go to #69)

68. Were the sIeeping areas for your famiIy members or friends comfortabIe?23911
-89
E

1
E

Don't know

Not at all

2
E

3
E

Somewhat

For the most part

69. OveraII, how wouId you rate the accommodations for your famiIy and visitors on a scaIe from 0 to 10, where 0 is "the worst" and 10 is "the
best"?23912
0 Worst
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 Best
10
E

We are interested in finding out whether people who used equipment during their hospital stay had enough space to get around.
70. WhiIe you were in the hospitaI, did you use any of the foIIowing equipment to get around? (Mark aII that appIy)24073
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 #74)

71. Was there enough space in the bathroom(s) to use equipment?13926
1
E

Yes

2
E

No

72. Was there enough space in the eIevators to use equipment?13927
1
E

Yes

2
E

No

73. Was there enough space in your room to move around with equipment?24074

B

1
E

Yes

2
E

No

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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

74. Having a private room13929
75. ControIIing the room temperature13932

1
E

2
E

3
E

4
E

76. ControIIing the indoor room Iighting13933

1
E

2
E

3
E

4
E

77. Having music (e.g., radio, tape pIayer, CD pIayer)13934

1
E

2
E

3
E

4
E

78. Having a teIevision and/or VCR13935

1
E

2
E

3
E

4
E

79. Having a private shower13936

1
E

2
E

3
E

4
E

80. Being abIe to find your way around13937

1
E

2
E

3
E

4
E

81. Having emaiI and Internet access23913

1
E

2
E

3
E

4
E

82. Access to areas in the hospitaI to sit or to waIk around23914

1
E

2
E

3
E

4
E

83. Access to outside green areas to sit or waIk23915

1
E

2
E

3
E

4
E

84. How wouId you rate the quaIity of the food service in the CIinicaI Center?1382
a. Courtesy of the person who took your food order23916

Poor
1
E

Fair
2
E

Good
3
E

Excellent
4
E

b. Variety of menu items23917

1
E

2
E

3
E

4
E

c. Received food in a timeIy manner (within 45 min. of order)23918

1
E

2
E

3
E

4
E

d. Temperature of the food23920

1
E

2
E

3
E

4
E

e. OveraII quaIity of the food23921

1
E

2
E

3
E

4
E

85. 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"?23922
0 Worst
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 Best
10
E

86. 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 OVERALL SENSE OF WELL-BEING?23923

B

0 Not at all
important
0
E

1
1
E

2
2
E

3
3
E

4
4
E

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5
E

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6
6
E

7
7
E

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8
E

9
9
E

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10 Extremely
important
10
E

B

B

87. 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 famiIy or visitors' OVERALL SENSE OF WELL-BEING?23924
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

88. Is there anything eIse you wouId Iike to teII us about how the HOSPITAL ENVIRONMENT infIuenced your experience during your hospitaI
stay?

Now we would like to ask you some questions about other aspects of your hospital experience.
89. Was it easy for you to find someone on the hospitaI staff to taIk to about your concerns?8188
1
E

Yes, definitely

2
E

3
E

Yes, somewhat

4
E

No

Didn't want to talk/no concerns

90. Did your famiIy or someone eIse cIose to you have enough opportunity to taIk to your doctor?8186
1
E
2
E

3
E
4
E

Yes, definitely
Yes, somewhat

5
E

No
No family or friends were involved

Family didn't want or need to talk

91. Did a doctor or nurse expIain the resuIts of tests in a way you couId understand?8191
1
E

2
E

Yes, completely

3
E

Yes, somewhat

4
E

No

No tests were done

92. Sometimes in the hospitaI, one doctor or nurse wiII say one thing and another wiII say something quite different. Did this happen to you?8184
1
E

2
E

Yes, always

3
E

Yes, sometimes

No

93. Did you feeI Iike you were treated with respect and dignity whiIe you were in the hospitaI?8193
1
E

2
E

Yes, always

3
E

Yes, sometimes

No

94. Were you ever in any pain?8194
1
E

Yes

2
E

No (Go to #97)

95. Do you think that the hospitaI staff did everything they couId to heIp controI your pain?8199
1
E

Yes, definitely

2
E

3
E

Yes, somewhat

No

96. OveraII, how much pain medicine did you get?8200
1
E

Not enough

2
E

Right amount

3
E

Too much

97. Did someone on the hospitaI staff expIain the purpose of the medicines you were to take at home in a way you couId understand?23925
1
E
2
E

Yes, completely
Yes, somewhat

3
E
4
E

5
E

No
Didn't need explanation

I didn't receive medicine to take home

98. Did they teII you when you couId resume your usuaI activities, such as when to go back to work or when you couId drive a car?23926

B

1
E

Yes, completely

2
E

Yes, somewhat

3
E

No

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99. Did the doctors and nurses give your famiIy or someone cIose to you aII the information they needed to heIp you recover?8210
1
E
2
E

Yes, definitely
Yes, somewhat

3
E
4
E

5
E

No
No family or friends involved

Family didn't want or need information

100. Upon your discharge from the hospitaI were you provided with adequate information regarding your condition and care?23927
1
E

Yes, completely

2
E

3
E

Yes, somewhat

No

101. OveraII, how wouId you rate the care you received at the hospitaI?8144
1
E

2
E

Poor

3
E

Fair

Good

4
E

Very Good

5
E

Excellent

And finally, we would like to get some information on your health and background.
102. In generaI, how wouId you rate your heaIth?8148
1
E

2
E

Poor

3
E

Fair

Good

4
E

Very Good

103. How many nights did you spend at the hospitaI?23928
1

1
E

2

2
E

3

3
E

5
E

4

4
E

Excellent

5

104. What was the Iast year of schooI you compIeted?8159
1
E
2
E

Less than high school graduate
High school graduate or GED

3
E
4
E

Some college, trade, or tech school
College graduate

105. Which of the foIIowing best describes your ethnic or raciaI background?23929
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

6
E

5
E

Asian
Black or African American
Native Hawaiian or Other Pacific Islander

10-15
7
E

More than 15
8
E

Post college graduate education

7
E

White

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

B

© NRC+Picker, All Rights Reserved

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