Form #2 6 Point Scale Questionnaire

CAHPS^® Clinician & Group Survey

Version: Adult Primary Care Questionnaire 1.0 – HIT Field Test Version

Language: English

Response Scale: 6 points

File name: 12454601 Last updated: May 15, 2009

Public reporting burden for this collection of information is estimated to average 20 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room #5036, Rockville, MD 20850.

Instructions for Front Cover

• Replace the cover of this document with your own front cover. Include a user-friendly title and your own logo.

• Include this text regarding the confidentiality of survey responses:

Your Privacy is Protected. All information that would let someone identify you or your family will be kept private. {VENDOR NAME} will not share your personal information with anyone without your OK. Your responses to this survey are also completely confidential. You may notice a number on the cover of the survey. This number is used only to let us know if you returned your survey so we don’t have to send you reminders.

Your Participation is Voluntary. You may choose to answer this survey or not. If you choose not to, this will not affect the health care you get.

What To Do When You’re Done. Once you complete the survey, place it in the envelope that was provided, seal the envelope, and return the envelope to [INSERT VENDOR ADDRESS].

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

Instructions for Format of Questionnaire

Proper formatting of a questionnaire improves response rates, the ease of completion, and the accuracy of responses. The CAHPS team’s recommendations include the following:

• If feasible, insert blank pages as needed so that the survey instructions (see next page) and the first page of questions start on the right-hand side of the questionnaire booklet.

• Maximize readability by using two columns, serif fonts for the questions, and ample white space.

• Number the pages of your document, but remove the headers and footers inserted to help sponsors and vendors distinguish among questionnaire versions.

Additional guidance is available in Preparing a Questionnaire Using the CAHPS Clinician & Group Survey: https://www.cahps.ahrq.gov/cahpskit/files/32_CG_Preparing_a_Questionnaire.pdf

Survey Instructions

Answer each question by marking 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 #1 on page 1

No

Your Doctor

1. Our records show that you got care from the doctor named below in the last 12 months.

Name of doctor label goes here

Is that right?

¹ Yes

² No  If No, go to #68 on page 9

The questions in this survey booklet will refer to the doctor named in Question 1 as “this doctor.” Please think of that doctor as you answer the survey.

2. Is this the doctor you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?

¹ Yes

² No

3. How long have you been going to this doctor?

¹ Less than 6 months

² At least 6 months but less than 1 year

³ At least 1 year but less than 3 years

⁴ At least 3 years but less than 5 years

⁵ 5 years or more

Your Care From This Doctor in the Last 12 Months

These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits.

4. In the last 12 months, how many times did you visit this doctor to get care for yourself?

None  If None, go to #68 on page 9

1 time

2

3

4

5 to 9

10 or more times

5. In the last 12 months, did you phone this doctor’s office to get an appointment for an illness, injury or condition that needed care right away?

¹ Yes

² No If No, go to #7

6. In the last 12 months, when you phoned this doctor’s office to get an appointment for care you needed right away, how often did you get an appointment as soon as you thought you needed?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

7. In the last 12 months, did you make any appointments for a check-up or routine care with this doctor?

¹ Yes

² No  If No, go to #9

8. In the last 12 months, when you made an appointment for a check-up or routine care with this doctor, how often did you get an appointment as soon as you thought you needed?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

9. In the last 12 months, how often was it easy to make an appointment at this doctor’s office?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

10. Can you make appointments at this doctor’s office by e-mail or on a website?

¹ Yes

² No  If No, go to #13

³ Don’t know  If Don’t know, go to #13

11. In the last 12 months, did you use e-mail or a website to make an appointment at this doctor’s office?

¹ Yes

² No  If No, go to #13

³ Don’t know  If Don’t know, go to #13

12. In the last 12 months, when you used e-mail or a website to get an appointment at this doctor’s office, how often did you get an appointment as soon as you thought you needed?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

13. In the last 12 months, did you ever fill out a medical history form on a website before a visit to this doctor?

¹ Yes

² No

14. In the last 12 months, did you phone this doctor’s office with a medical question during regular office hours?

¹ Yes

² No  If No, go to #16

15. In the last 12 months, when you phoned this doctor’s office during regular office hours, how often did you get an answer to your medical question that same day?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

16. In the last 12 months, did you phone this doctor’s office with a medical question after regular office hours?

¹ Yes

² No  If No, go to #18

17. In the last 12 months, when you phoned this doctor’s office after regular office hours, how often did you get an answer to your medical question as soon as you needed?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

18. In the last 12 months, did you e-mail this doctor’s office with a medical question?

¹ Yes

² No  If No, go to #21

19. In the last 12 months, when you e-mailed this doctor’s office, how often did you get an answer to your medical question as soon as you needed?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

20. In the last 12 months, when you e-mailed this doctor’s office, how often were all of the questions in your e-mail answered?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

21. In the last 12 months, did this doctor’s office ever send you an e-mail to remind you about tests or treatment you needed?

¹ Yes

² No

22. Wait time includes time spent in the waiting room and exam room. In the last 12 months, how often did you see this doctor within 15 minutes of your appointment time?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

23. In the last 12 months, how often did this doctor explain things in a way that was easy to understand?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

24. In the last 12 months, how often did this doctor listen carefully to you?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

25. In the last 12 months, did you talk with this doctor about any health problems or concerns?

¹ Yes

² No  If No, go to #28

26. In the last 12 months, how often did this doctor give you easy to understand instructions about taking care of these health problems or concerns?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

27. In the last 12 months, how often did this doctor seem to know the important information about your medical history?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

28. In the last 12 months, how often did this doctor show respect for what you had to say?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

29. In the last 12 months, how often did this doctor spend enough time with you?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

30. Choices for your treatment or health care can include things like medicine, surgery, or other treatment. In the last 12 months, did this doctor tell you there was more than one choice for your treatment or health care?

¹ Yes

² No  If No, go to #33

31. In the last 12 months, did this doctor talk with you about the pros and cons of each choice for your treatment or health care?

¹ Yes

² No

32. In the last 12 months, when there was more than one choice for your treatment or health care, did this doctor ask which choice you thought was best for you?

¹ Yes

² No

33. In the last 12 months, did this doctor order a blood test, x-ray or other test for you?

¹ Yes

² No  If No, go to #35

34. In the last 12 months, when this doctor ordered a blood test, x-ray or other test for you, how often did someone from this doctor’s office follow up to give you those results?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

35. Using any number from 0 to 10, where 0 is the worst doctor possible and 10 is the best doctor possible, what number would you use to rate this doctor?

0 Worst doctor possible

1

2

3

4

5

6

7

8

9

10 Best doctor possible

36. In the last 12 months, did you need a prescription for medicine from this doctor for yourself?

¹ Yes

² No  If No, go to #39

37. In the last 12 months, did you ever use e-mail or a website to ask this doctor to refill or renew one of your prescriptions?

¹ Yes

² No

38. In the last 12 months, did you ever use e-mail or a website to ask this doctor to prescribe a new medicine for you?

¹ Yes

² No

39. Doctors may use computers or handheld devices during an office visit to do things like look up your information or order prescription medicines. In the last 12 months, did this doctor use a computer or handheld device during any of your visits?

¹ Yes

² No  If No, go to #45

40. During your visits in the last 12 months, did this doctor ever use a computer or handheld device to look up test results or other information about you?

¹ Yes

² No

³ Don’t know

41. During your visits in the last 12 months, did this doctor ever use a computer or handheld device to show you information?

¹ Yes

² No

42. In the last 12 months, did this doctor ever use a computer or a handheld device to order your prescription medicines?

¹ Yes

² No

³ Don’t know

43. During your visits in the last 12 months, was this doctor’s use of a computer or handheld device helpful to you?

¹ Yes, definitely

² Yes, somewhat

³ No

44. During your visits in the last 12 months, did this doctor’s use of a computer or handheld device make it harder or easier for you to talk with him or her?

¹ Harder

² Not harder or easier

³ Easier

Clerks and Receptionists at This Doctor’s Office

45. In the last 12 months, how often were clerks and receptionists at this doctor’s office as helpful as you thought they should be?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

46. In the last 12 months, how often did clerks and receptionists at this doctor’s office treat you with courtesy and respect?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

Website Information Provided By This Doctor’s Office

47. Does this doctor’s office put your laboratory or other test results on a website for you to see?

¹ Yes

² No  If No, go to #52

³ Don’t know  If Don’t know, go to #52

48. In the last 12 months did you look for your lab or other test results on the website?

¹ Yes

² No  If No, go to #52

49. In the last 12 months, how often was it easy to find these lab or other test results on the website?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

50. In the last 12 months, how often were these lab or other test results put on the website as soon as you needed them?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

51. In the last 12 months, how often were these lab or other test results presented in a way that was easy to understand?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

52. Does this doctor’s office put a list of your prescription medicines on a website for you to see?

¹ Yes

² No  If No, go to #55

³ Don’t know  If Don’t know, go to #55

53. In the last 12 months, did you look at this list of your prescription medicines on the website?

¹ Yes

² No  If No, go to #55

54. In the last 12 months, how often was the list of prescription medicines up to date?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

55. Visit notes sum up what was talked about on a visit to a doctor’s office. Visit notes may be available on paper, on a website or by e-mail. In the last 12 months, did this doctor’s office offer you visit notes?

¹ Yes

² No  If No, go to #59

³ Don’t know  If Don’t know, go to #59

56. In the last 12 months, how did this doctor’s office offer you the visit notes? Mark one or more.

¹ On paper

² On a website

³ By e-mail

⁴ Some other way

57. In the last 12 months, did you look at any visit notes from this doctor’s office?

¹ Yes

² No  If No, go to #59

58. In the last 12 months, how often were the visit notes easy to understand?

¹ Never

² Almost never

³ Sometimes

⁴ Usually

⁵ Almost always

⁶ Always

More Questions About Your Care in the Last 12 Months

These next questions may seem the same as questions you’ve already answered.

59. In the last 12 months, how often did this doctor explain things in a way that was easy to understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

60. In the last 12 months, how often did this doctor listen carefully to you?

¹ Never

² Sometimes

³ Usually

⁴ Always

61. In the last 12 months, did you talk with this doctor about any health problems or concerns?

¹ Yes

² No  If No, go to #64

62. In the last 12 months, how often did this doctor give you easy to understand instructions about taking care of these health problems or concerns?

¹ Never

² Sometimes

³ Usually

⁴ Always

63. In the last 12 months, how often did this doctor seem to know the important information about your medical history?

¹ Never

² Sometimes

³ Usually

⁴ Always

64. In the last 12 months, how often did this doctor show respect for what you had to say?

¹ Never

² Sometimes

³ Usually

⁴ Always

65. In the last 12 months, how often did this doctor spend enough time with you?

¹ Never

² Sometimes

³ Usually

⁴ Always

66. In the last 12 months, how often were clerks and receptionists at this doctor’s office as helpful as you thought they should be?

¹ Never

² Sometimes

³ Usually

⁴ Always

67. In the last 12 months, how often did clerks and receptionists at this doctor’s office treat you with courtesy and respect?

¹ Never

² Sometimes

³ Usually

⁴ Always

About You

68. Do you ever use e-mail or the Internet?

¹ Yes

² No

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

¹ Excellent

² Very good

³ Good

⁴ Fair

⁵ Poor

70. A health provider is a doctor, nurse or anyone else you would see for health care. In the past 12 months, have you seen a doctor or other health provider three or more times for the same condition or problem?

¹ Yes

² No  If No, go to #72

71. Is this a condition or problem that has lasted for at least 3 months? Do not include pregnancy or menopause.

¹ Yes

² No

72. Do you now need or take medicine prescribed by a doctor? Do not include birth control.

¹ Yes

² No  If No, go to #74

73. Is this medicine to treat a condition that has lasted for at least 3 months? Do not include pregnancy or menopause.

¹ Yes

² No

74. What is your age?

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

75. Are you male or female?

¹ Male

² Female

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

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

77. Are you Hispanic or Latino/Latina?

¹ Yes

² No

78. What is your race? Please mark one or more.

¹ American Indian or Alaska Native

² Asian

³ Black or African-American

⁴ Native Hawaiian or Other Pacific Islander

⁵ White

79. Did someone help you complete this survey?

¹ Yes

² No  Thank you.
Please return the completed survey in the postage-paid envelope.

80. How did that person help you? Mark all that apply.

¹ Read the questions to me

² Wrote down the answers I gave

³ Answered the questions for me

⁴ Translated the questions into my language

⁵ Helped in some other way

Please print:

Thank you.

Please return the completed survey in the postage-paid envelope.