CMS-10197 Appendix B Statistical Instruments

Evaluation of Medicare National Competitive Bidding Program for DME

CMS-10197 AppendixBStatisticalInstruments32610

Statistical Data - Households

OMB: 0938-1015

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APPENDIX B:
Statistical Instruments

OMB# 0938-XXX
ABT ID #

Survey of
Medicare Patients Who Use
Oxygen Equipment
The purpose of the study is to learn more about your satisfaction with the
equipment, supplies, and service you receive from your oxygen (or other
durable medical equipment) supplier. We also hope to better understand
your experiences in obtaining and using this equipment.

1

If the person this survey was mailed to cannot complete the survey, and
there is no one else who can do so for him or her, please check here and
return the blank survey in the enclosed postage-paid envelope.

Please return by ______________.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-NEW. The time required to complete this information collection is estimated to
average 30 minutes per response, including the time to review instructions, search existing data resources,
gather the data needed, and complete and review the information collection. If you have comments concerning
the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 212441850.

Abt Associates, Inc.
CMS 10197-BOS

Beneficiary Oxygen Survey

Instructions
The questions in this survey ask about your experiences as a person who uses oxygen
equipment.
To complete the survey, please answer the questions by checking the box to the left of your
answer (as shown below). You are sometimes told to skip over some questions in this survey.
When this happens you will see an arrow beside your response with a note that tells you which
question to answer next, like this:
 Yes
 No → Skip to A5
 I don’t know

If there is no arrow next to your response, please proceed to the next question.
Some people might ask someone else (maybe a spouse, child, or friend) to help them
complete this survey. If someone is helping you fill out the survey, remember that the
questions always refer to you and your experience with oxygen treatment and equipment.

Confidentiality
All information that would let someone identify you or your family will be kept
confidential. You may choose to answer this survey or not. If you choose not to,
this will not affect the Medicare benefits you get. You may notice a number on
the cover of this survey. This number is ONLY used to let us know if you
returned your survey so we won’t send you reminders.
If you have any questions about the survey, please call Abt Associates, the
survey company, at 1-888-XXX-XXXX.
This is a toll-free call.

Abt Associates, Inc.
CMS 10197-BOS

Beneficiary Oxygen Survey

USE OF OXYGEN SYSTEMS
A1. When did you begin using
oxygen equipment and tanks at
home?
1
2
3
4
5

2010
2009
2008
Before 2008
I have never used oxygen
equipment at home (Skip to
SECTION G on page 19)

A2. When you first began using
oxygen equipment and tanks at
home, how long did you expect to
use it?
1 Less than 1 month
2 1 to 6 months
3 More than 6 months
4 Forever
98 I don’t know
A3. Do you use any type of oxygen
system now? This includes
using oxygen all of the time, with
exercise or walking only, at night
only, or using it with another
medical device such as a
ventilator or a CPAP machine? (A
CPAP machine blows air through
a hose into a face mask or
ventilator, to improve breathing
while asleep.)
1
2

A3a. Why did you stop using oxygen?
(Please check all that apply and
then go to SECTION G on p. 19.)
I believed that my breathing got
better so I did not need it anymore
2 My doctor said I did not need it
3 Oxygen therapy costs too much
4 I just did not like using it
5 Equipment was too heavy or
cumbersome
6 Equipment kept breaking down
7 I had a problem getting the supplies
from my oxygen supplier
8 I was embarrassed to use it
96 Other, please specify:
________________________
1

YOUR CURRENT USE OF OXYGEN
SYSTEM
A4. When did you first get the oxygen
equipment you use now?
1
2
3

Less than 6 months ago
6-12 months ago
More than 12 months ago

A5. Did you get your current oxygen
system while you were in a
nursing home or hospital?
1
2

Yes
No

Yes (→Skip to A4)
No, I no longer use Oxygen

Abt Associates Inc.

Beneficiary Oxygen Survey

A6. Does someone regularly help you
use your oxygen equipment (for
example, a relative, friend, or
home health aide)?
1 Yes
2 No

A8.

If a respiratory therapist was the
professional who explained your
oxygen equipment, where was
the information provided?
(Please check all that apply.)

1

Information was provided in my
home
Information was provided while I
was in the hospital
A respiratory therapist did not
provide me with information
I don’t know

2
A respiratory therapist is a specially
trained professional who helps you
improve your breathing.
A7. Did a respiratory therapist or
another medical person like a
doctor or a nurse ever explain the
following to you (Please check all
that apply):
1 Oxygen equipment options and
which might be best for you
2 Why you need to use oxygen
equipment
3 How much oxygen you need
4 When to use your oxygen
equipment
98 None of these things were
explained by a respiratory therapist,
doctor, or nurse

Abt Associates Inc.

3
98

A9. How often does a medical person
like a nurse or a respiratory
therapist come to your home and
clip an oxygen measurement
device to your fingertip, to
measure your oxygen?
1
2
3
98

At least once each month
A few times each year
No one ever comes to my home to
do a fingertip oxygen measurement
I don’t know

Beneficiary Oxygen Survey

A10. When was the last time you
discussed your need for oxygen
with a doctor or another medical
person like a nurse or a respiratory
therapist?
1
2
3
4
98

Within the last 6 months
Between 6 months and 1 year ago
Between 1 and 3 years ago
More than 3 years ago
I don’t know

A11. Are you still using the same oxygen
equipment as when you first
started using oxygen at home?
1
2
98

Yes (→Skip to A12)
No
I don’t know (→Skip to A12)

A11a. If you have different oxygen
equipment, why did you make a
change? (Please check all that
apply.)
1 Equipment needed to be replaced
because it did not work
2 My condition/breathing changed
3 I found new equipment that was
better for me
4 My supplier became ineligible to
provide my equipment under
Medicare
5 My supplier told me Medicare no
longer covered equipment
6 Doctor prescribed a different type of
equipment
7 My supplier did not tell me why they
changed my equipment
99 Other, please specify:
____________________________

A12. Do you believe that you now
have the oxygen equipment that
is right for you?
1 Yes
2 No
98 I don’t know

Abt Associates Inc.

Beneficiary Oxygen Survey

A13.Is using your current oxygen
equipment difficult or
uncomfortable?
1 Yes
2 No (→Skip to A14)
98 I don’t know (→Skip to A14)
A13a.What is it about your current
oxygen equipment that makes it
difficult or uncomfortable to use?
(Please check all that apply.)
1
2

3
4

5

6
7
8
9
10
99

Equipment makes it difficult to
move freely around my home
Equipment makes it difficult to go
outside of my home for a short
walk
Equipment makes it difficult to go
to the doctor when I need to
Equipment makes it difficult to go
to church, visit friends, shop, or
leave the house for more than a
short time
Equipment is too heavy or
cumbersome (hard to lift, doesn’t
fit easily into the car)
Equipment doesn’t supply enough
oxygen
I’m afraid I will run out of oxygen
Equipment breaks down a lot or is
undependable
Equipment is too complicated for
me to use
I am embarrassed to use the
equipment outside my home
Other, please specify:

A14. Does using the oxygen
equipment make you feel better?
1 Yes
2 No
98 I don’t know

A15. Are you using less oxygen than
your doctor, nurse or respiratory
therapist recommended?
1
2

3
4
98

Yes, I use it for fewer hours per
day than my doctor recommended
Yes, I use it for fewer days each
week than my doctor
recommended
Yes, I use a lower flow rate than
my doctor recommended
No (→Skip to SECTION B)
I don’t know (→ Skip to SECTION
B)

___________________________

Abt Associates Inc.

Beneficiary Oxygen Survey

A15a.Please tell us why you are
using less oxygen than your
doctor or other medical person
recommended. (Please check
all that apply.)
1

2
3
4
5
6
7
8
96

I believe that my breathing got
better so I don’t need oxygen as
much
Oxygen therapy costs too much
I just don’t like using it
I am embarrassed to use it
Equipment is too heavy or
cumbersome
Equipment keeps breaking down
Equipment is too complicated for
me to use
I have a problem getting the
supplies from my oxygen supplier
Other, please specify:

__________________________

Abt Associates Inc.

Beneficiary Oxygen Survey

STATIONARY OXYGEN

Stationary oxygen systems are heavy
pieces of equipment that you cannot
move easily.
These include non-portable oxygen
concentrators, liquid oxygen vessels,
and large compressed gas oxygen
cylinders.
B1. Do you use any type of
stationary oxygen system now?
1
2

Yes
No (→Skip to SECTION C)

Oxygen
Concentrator
Machine

Abt Associates Inc.

Liquid Oxygen
Vessel

B2. What type of stationary oxygen
system(s) do you usually use at
home? (Please check all that
apply.)
1 Oxygen concentrator machine (unit
that plugs into the wall and
produces oxygen) [pictured below at
left]
2 Liquid oxygen vessel (large tank
that is usually placed in the home
and not moved) [pictured below at
center]
3 Large compressed oxygen cylinder
(resembles a welding tank) [pictured
below at right]
4 Oxygen concentrator system that
allows you to fill small cylinders [not
pictured]
98 I don’t know

Large Compressed
Gas Oxygen
Cylinder

Beneficiary Oxygen Survey

B3. What type of oxygen delivery
device do you breathe from to
get your oxygen? (Please check
all that apply.)
1
2

3

4
5
6
98

Nasal cannula (nose prongs/tubes)
Transtracheal catheter (very thin
tube that goes directly in your
throat)
Reservoir cannula: small oxygen
storage chamber positioned below
nose or on your chest
Oxygen mask
Connection to your tracheostomy
tube
Connection to my CPAP machine,
bi-level device, or ventilator
I don’t know

B4. In general, how often do you use
your stationary oxygen system?
1
2
3
4
5

Less than one day a week
1-2 days per week
3-4 days per week
5-6 days per week
Every day

Abt Associates Inc.

B5. On the days that you do use
stationary oxygen, for how many
hours do you use it (out of 24
hours in a day)?
______ hours per day

Sometimes people have serious
problems with their stationary systems
and are forced to stop using oxygen or to
use another source of oxygen, such as a
portable tank or emergency back-up
tank.
B6. Have you had any serious
problems that made you stop
using your stationary oxygen
system?
1 Yes
2 No (→ Skip to SECTION C)
98 I don’t know (→ Skip to SECTION C)

Beneficiary Oxygen Survey

B6a. Can you describe the kind of
problem(s) that you had?
(Please check all that apply.)
Power outage in my home
Equipment failed or did not work
Unit ran out of liquid oxygen or
compressed oxygen
96 Other, please specify:
___________________________
98 I don’t know

1
2
3

B6b. How many times did you have
these kinds of problems in the
past year?
1
2
3
4

One time
2 or 3 times
4 or more times
Don’t recall the exact number of
times

Abt Associates Inc.

Beneficiary Oxygen Survey

C. PORTABLE OXYGEN
Portable oxygen systems let you keep
using oxygen when you are away from
the stationary system. They may be light
enough to carry on a strap over your
shoulder or to pull on a wheeled cart.
Your portable oxygen system may be a
small gaseous oxygen tank, a small
liquid oxygen cylinder, or a small
portable oxygen concentrator.

C1. Do you use any type of portable
oxygen system now?
1 Yes
2 No (→Skip to SECTION D)
98 I don’t know

Mid-Sized
Compressed
Oxygen Tank

Abt Associates Inc.

C2. What type of portable oxygen
system(s) do you use? (Please check
all that apply.)
1 Mid-sized compressed oxygen tank (Ecylinder, resembles a diving tank and
can roll on a cart) [pictured below at left]
2 Very small and light compressed
oxygen tank that concentrates room
oxygen (can carry on your shoulder)
[pictured below at right]
3 Mid-sized or standard portable liquid
oxygen unit [pictured below in center]
4 Very small liquid portable unit (can carry
on your shoulder or belt and that must
be refilled) [not pictured]
5 Small portable oxygen concentrator that
concentrates room oxygen [not
pictured]
6 Small portable concentrator that
concentrates room oxygen and also
serves as a stationary source [not
pictured]
98 I don’t know
96 Other portable oxygen system:
__________________________

Standard
Portable Liquid
Unit

________
________

Beneficiary Oxygen Survey

Small
Compressed
Oxygen Tank

C3. In general, how often do you use
your portable oxygen system?
1
2
3
4
5

Less than one day a week
1-2 days per week
3-4 days per week
5-6 days per week
Every day

C4. On the days that you use portable
oxygen, for how many hours do
you use it (out of 24 hours in a
day)?
______ hours per day

C5. Is your portable oxygen system
meeting your needs?
1 Yes (→Skip to C6)
2 No
98 I don’t know (→Skip to C6)

C5a.Please tell us why your portable
oxygen system is not meeting
your needs. (Please check all
that apply.)
1I believe that my breathing got better
so I don’t need oxygen as much
2Oxygen therapy costs too much
3I just don’t like using it
4I am embarrassed to use it
5Equipment is too heavy or
cumbersome
6Equipment keeps breaking down
7Equipment is too complicated for me
to use
8I have a problem getting the supplies
from my oxygen supplier
9 I’m using a different oxygen system
10 I’m afraid I will run out of oxygen
96 Other, please specify:

C6. In general, how often do you get
deliveries/refills from your
oxygen supplier for your
portable oxygen system? This
may include oxygen tank
deliveries, liquid oxygen refills,
etc.
14 times a month
22-3 times a month
3Once a month
4Once every year
5Less than once per year
6I don’t get refills of any type
98 I don’t know

Abt Associates Inc.

Beneficiary Oxygen Survey

D. MEDICAL EXPENSES
An intermittent flow device gives you
oxygen only when you breathe in.
Examples of these oxygen-conserving
devices are pulse-dosing oxygen
regulators and small liquid portable units
or portable concentrators that use a
pulse-dosing oxygen regulator.
C7. Do you use any type of intermittent
flow device with your portable
system now?
1 Yes
2 No (→ Skip to SECTION D)
98 I don’t know (→ Skip to SECTION D)

C7a.When you first received your
oxygen equipment that was
equipped with an intermittent flow
device, who adjusted the device?
(Please check all that apply.)
1 Home oxygen supplier or a
respiratory therapist from the supplier
2 Doctor
3 Other medical personnel
4 No one
5 Don’t remember if anyone did
98 I don’t know who it was

Abt Associates Inc.

D1. In the past year, have you bought
any oxygen equipment or supplies
with your own money because
your insurance did not cover it?
(This does not include any copay
or deductible amounts that are due
from you.)
1 Yes
2 No (→ Skip to SECTION E)
98 I don’t know (→ Skip to SECTION E)
D2. In the past year, what oxygen
equipment or supplies did you buy
with your own money? (Please
check all that apply.)
1 Extra portable oxygen system
2 Extra stationary oxygen system
3 Oxygen conserving/intermittent flow
device
4 Special nasal cannula
5 Transtracheal supplies
98 I don’t know
96 Other, please specify:
___________________________

Beneficiary Oxygen Survey

D3. Thinking about everything you
paid for with your own money in
the past year for the oxygen
equipment and supplies that were
not covered by insurance, how
much did you spend? (This does
not include any copay or
deductible amounts.)
1
2
3
4
98

Less than $100
$100-$500
$500 to $1,000
$1,000 to $2,000
I don’t know

E. YOUR SUPPLIER
E1. Considering the oxygen equipment
you have now, did you have any
problems finding an equipment
supplier to get it from?
1 Yes
2 No (→ Skip to E2)
98 I don’t know (→ Skip to E2)
E1a. What kinds of problems did you
have finding an oxygen supplier?
(Please check all that apply.)
1 Hard to find a supplier who covered
my area
2 Supplier did not carry what I needed
3 Supplier could not deliver equipment
when I needed it
4 Supplier did not accept Medicare
96 Other, please describe:
______________________

98 I don’t know
E2. Considering the oxygen equipment
you have now, did you have a
choice of suppliers?
1
2
3
98

Abt Associates Inc.

Yes, many
Yes, a few
No, only one supplier available
I don’t know

Beneficiary Oxygen Survey

E3. Considering the oxygen equipment
you have now, when you asked
your supplier questions, did you
get answers that you could
understand?
1
2
3
4
98

Yes, completely
Yes, somewhat
No
I did not ask any questions
I don’t know

E4. Before deciding on the oxygen
equipment you use now, did your
supplier tell you as much as you
wanted to know about the options
for your oxygen equipment?
1 Yes, completely
2 Yes, somewhat
3 No
E4a. Before you decided on the oxygen
equipment that you use now, did
your supplier tell you about all the
equipment designs available to
you, even those which the supplier
did not have in stock?
1 Yes, all equipment designs were
explained
2 No, the supplier only told me what
he/she has in stock
3 No, I already knew the equipment
designs available to me
98 I don’t know

Abt Associates Inc.

E5. After the order was placed for your
oxygen equipment, how long did it
take to arrive?
1
2
3
4
98

Same day
Next day
Within a week
More than 1 week later
I don’t know

E6. When you got the oxygen
equipment you use now, what kind
of training or help did the supplier
give you or the person who takes
care of you? (Please check all that
apply.) Did he/she…
1 Give you written instructions on how
to use the equipment or supplies
2 Show you how to use the equipment
or supplies
3 Choose a safe and convenient place
to store the equipment or supplies
4 Show you how to clean and maintain
the equipment or supplies
5 Show you how to use oxygen safely
6 Let you practice how to use and maintain
your equipment and supplies while they
watched
7 Give you the manufacturer’s
customer assistance toll-free
telephone number
8 I did not get any training or help from
my oxygen supplier (→ Skip to E7)
98 I don’t know (→ Skip to E7)

Beneficiary Oxygen Survey

E6a. As a result of that training, how
comfortable do you feel using and
maintaining your oxygen
equipment?
1
2
3
4
5

Very comfortable
Comfortable
Uncomfortable
Very uncomfortable
My comfort level has nothing to do
with the training that my supplier
gave me

E7. In the first 3 months after you got
the oxygen equipment you use
now, how often did a nurse or
respiratory therapist come to your
home to check on how you are
doing and if you are getting
enough oxygen?
1 Once in the 3 months after you got
the oxygen equipment
2 More than once in the 3 months after
you got the oxygen equipment
3 Not at all in the 3 months after you
got the oxygen equipment
4 I don’t know or recall the clinical
specialty of the person who came to
my home.

Abt Associates Inc.

E8. In the first 3 months after you got
the oxygen equipment you use now,
how often did your supplier send
someone to your home to check the
equipment? (Do not include times
when you called them.)
1 Once in the 3 months after you got
the oxygen equipment
2 More than once in the 3 months after
you got the oxygen equipment
3 Not at all in the 3 months after you
got the oxygen equipment

E9. How do you get your oxygen refills
and supplies? (Please check all
that apply.)
1 Delivered to my home by my supplier
2 Mailed to my home by my supplier
3 I pick them up from my oxygen
supplier
4 Someone picks them up for me
98 I don’t know
96 Some other way, please tell us how:
_____________________________

Beneficiary Oxygen Survey

E10. Considering the oxygen equipment
you have now, how much time and
energy does it take to get your
oxygen equipment, supplies,
maintenance and repairs from your
supplier?
1
2
3
4
98

No time and energy
A little time and energy
Some time and energy
A lot of time and energy
I don’t know

E11. Do you currently get your current
oxygen equipment, supplies,
maintenance and repairs from
more than one equipment
supplier?

E12. Overall, how would you rate the
supplier that you use most?
1
2
3
4
5

Poor
Fair
Good
Very good
Excellent

E13. Would you recommend this
oxygen supplier to a friend who
needed similar services?
1
2

Yes
No

1 Yes
2 No
98 I don’t know

Abt Associates Inc.

Beneficiary Oxygen Survey

RECENT EXPERIENCES

F1. During the past six months, how
reliable was your oxygen supplier
in making deliveries?
1
2
3
4

Very reliable
Somewhat reliable
Not reliable at all
Does not apply

F2. In the past six months, have you
contacted your oxygen supplier
with a complaint or a problem?
1
2
98
4

Yes
No (→ Skip to F4)
I don’t know (→ Skip to F4)
Don’t know how to contact my
oxygen supplier (→ Skip to F4)

F2a. When you contacted your oxygen
supplier, was your complaint or
problem settled to your
satisfaction?
1
2
3
98

Yes
No
I am waiting for it to be settled
I don’t know

Abt Associates Inc.

F3.

In the past six months, have you
contacted your oxygen supplier to
get emergency service or advice?

1 Yes
2 No (→ Skip to F4)
98 I don’t know (→ Skip to F4)
F3a. In general, how fast did the
supplier respond to your needs,
either by phone or in person?
Would you say…
1
2
3
4
98

Within 1 day
Within 2 days
Within 1 week
Longer than 1 week
I don’t know

F3b. Were you able to get the
emergency service or advice you
needed?
1 Yes
2 No
98 I don’t know
F4.

In the past six months, have you
needed to contact your supplier
after regular business hours?

1 Yes
2 No (→ Skip to F5)
98 I don’t know (→ Skip to F5)

Beneficiary Oxygen Survey

F4a. When you contacted your
supplier after business hours, in
general were you able to get the
service or advice you needed?
1
2
98

Yes
No
I don’t know

F5.

In the past six months, how
reliable has your oxygen
equipment been? Would you
say…

1
2
3
4
98

Very reliable
Somewhat reliable
Somewhat unreliable
Very unreliable
I don’t know

F6.

In the past six months, have you
changed your oxygen supplier?

1
2
98

Yes
No (→ Skip to SECTION G)
I don’t know (→ Skip to SECTION G)

F6a. Why did you change your oxygen
supplier? (Please check all that
apply.)
1
2
3
4
5
6
7
8
9

10

11
12
96

I moved
Supplier no longer accepted
Medicare
Supplier went out of business
I was not happy with the quality of
service
I was not happy with equipment
I was not happy with the choices of
equipment or service I could get
I was not happy with the assistance I
got in handling the insurance
Supplier did not provide the oxygen
equipment or accessories I needed
I was not happy with the amount of
oxygen my supplier was delivering to
my home for my stationary oxygen
unit
I was not happy with the amount of
oxygen my supplier was delivering for
my portable unit
I changed to an HMO and had to use
a different supplier
Supplier became ineligible to provide
the equipment under Medicare
Other, please specify:

__________________________

Abt Associates Inc.

Beneficiary Oxygen Survey

ABOUT YOU

Section G is about you, the person whose
name is on the mailing label of this survey.

G5. What is the highest grade or level of scho
that you have completed?

G1. In general, how would you rate
your overall health?

1
2
3
4
5
6

1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

G2. Compared to 1 year ago, how
would you rate your health now?
Would you say…
1
2
3
4
5

Much better now
Somewhat better now
About the same
Somewhat worse now
Much worse now

G3. Do you currently live alone?
1 Yes (→Skip to G5)
2 No
G4. Which best describes your living
situation now? (Please check all
that apply.) I live…
1
2
3
4
5
6

With spouse/partner
With parent/step-parent
With child/children
With other relative(s)
With friend
With other person(s) not related to me

Abt Associates Inc.

8th grade or less
Some high school but did not graduate
High school graduate or GED
Some college or technical school
College graduate
More than a 4-year college degree

G6. What was your household’s annual
income during 2009 before taxes?
1
2
3
4
5
6

Less than $5,000 ($416 per month)
Between $5,001 and $10,000 ($417–
$833 per month)
Between $10,001 and $20,000
($834–$1,666 per month)
Between $20,001 and $30,000
($1,667–2,500 per month)
Between $30,001 and $50,000
($2,501–$4,167 per month)
Over $50,000 (over $4,168 per
month)

G7. Are you of Hispanic or Latino
heritage?
1
2

Yes
No

Beneficiary Oxygen Survey

H. OTHER INFORMATION
G8. How would you describe your
race? (Please check all that apply.)
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific
Islander
5 White or Caucasian
99 Other, please tell us:
_________________________
1
2
3
4

H1. Please check the correct
statement:
1
2

I am the person to whom this survey
was addressed (→ Skip to END)
I filled this survey out or helped fill it
out for someone else

H2. How did you help the person with
this survey?
1
2

3

I wrote the answers that the person
told me
I answered the questions myself
based on my knowledge of the
person’s condition
Both of the above

END

Abt Associates Inc.

Beneficiary Oxygen Survey

Thank you for completing the survey. Please return the completed survey in the
postage-paid envelope addressed to:

Survey of Medicare Patients
Abt Associates Inc.
55 Wheeler Street,
Cambridge, MA 02138

If you have any questions about the survey, please call toll-free 1-xxx-xxx-xxxx.
If you have any questions about Medicare, please visit the website of the Center for
Medicare Services at: http://www.medicare.gov/, or call 1-800-MEDICARE.

Abt Associates Inc.

Beneficiary Oxygen Survey

OMB# 0938-NEW
1001

Survey of
Medicare Patients Who Use a
Continuous Positive Airway
Pressure (CPAP) Machine
The purpose of the study is to learn more about your satisfaction with the
equipment, supplies, and service you receive from your CPAP machine
supplier. We also hope to better understand your experiences in obtaining
and using this equipment.

1

Please return by ______________.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-NEW. The time required to complete this information collection is estimated to average 30
minutes per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn:
PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

CPAP Machine Survey

Instructions
The questions in this survey ask about your experiences as a person who
uses a CPAP machine.
To complete the survey, please answer the questions by checking the box to the
left of your answer (as shown below). You are sometimes told to skip over some
questions in this survey. When this happens you will see an arrow beside your
response with a note that tells you which question to answer next, like this:
 Yes
 No → Skip to A5
 I don’t know

If there is no arrow next to your response, please proceed to the next question.
Some people might ask someone else (maybe a spouse, child, or friend) to help
them complete this survey. If someone is helping you fill out the survey,
remember that the questions always refer to you and your experience with your
CPAP machine.

CPAP Machine Survey

USE OF CPAP MACHINES

A1. When did you begin using a CPAP
machine?
1
2
3
4
5

2010
2009
2008
Before 2008
I have never used a CPAP machine
(Skip to SECTION E on page 13)

A2. When you first began using a CPAP
machine, how long did you expect to
use it?
1
2
3
4
98

Less than 1 month
1 to 6 months
More than 6 months
Forever
I don’t know

A3. Do you use a CPAP machine now?
This includes using a CPAP machine
all of the time or just occasionally.
1 Yes (→Skip to A4)
2 No, I no longer use a CPAP machine

A3a. Why did you stop using your CPAP
machine? (Please check all that
apply and then skip to SECTION E
on page 11.)
My condition got better so I did not
need it anymore
2 My condition got worse so I couldn’t
use it anymore
3 I was embarrassed to use it
4 I was not comfortable using it
6 I just did not like using it
7 It was too difficult to use
8 It kept breaking down
9 The mask did not fit properly
10 It did not have the features I needed
96 Other, please specify:
________________________
1

YOUR CURRENT USE OF CPAP
MACHINE
A4. When did you first get the CPAP
machine you use now?
1
2
3

Less than 6 months ago
6-12 months ago
More than 12 months ago

A5. Did you get your current CPAP
machine when you were in a nursing
home or hospital?
1
2

Yes
No

CPAP Machine Survey

A6. Does someone regularly help you use
your CPAP machine (for example, a
relative, friend or home health aide)?

A8. When was the last time you

discussed your needs or issues
related to your CPAP machine
with a respiratory therapist or
another medical person like a doctor
or nurse?

1 Yes
2 No

A respiratory therapist is a specially trained
professional who helps you improve your
breathing.
A7. Did a respiratory therapist or another
medical person like a doctor or nurse
ever explain the following to you
(Please check all that apply):
1 Why you needed to use a CPAP
machine
2 The different types of CPAP machines,
control options, and accessories
3 None of these things were explained by a
medical person
98 I don’t know or don’t recall if a medical
person explained anything to me

1
2
3
4
98

Within the last 6 months
Between 6 months and 1 year ago
Between 1 and 3 years ago
More than 3 years ago
I don’t know

A9. Have you had more than one CPAP
machine in the past year, or changed
accessories (for example, hoses, mask)
in the past year? (Please check all that
apply.)
1 No (→Skip to A10)
2 Yes, I changed my CPAP machine
3 Yes, I changed or added
accessories
98 I don’t know (→Skip to A10)

CPAP Machine Survey

A9a.Why did you make this (these) change(s)? A11a. What is it about your CPAP
(Please check all that apply.)
machine that makes it difficult or
uncomfortable to use? (Please
1 My CPAP machine needed to be
check all that apply.)
replaced because the original one did
not work
1 Equipment makes it difficult to
2 My medical condition changed, so I
move in my sleep
needed something different
2 Equipment makes it difficult to
3 I found a new CPAP machine that was
sleep well
better for me
3 CPAP machine is too noisy (for me
4 I found new features/accessories that
or my partner)
were better for me
4 The mask is uncomfortable
5 My doctor/ health care provider
5 It’s difficult to take the machine with
prescribed a different type of CPAP
me when I travel away from home
machine
6 Do not like to be dependent on a
6 My supplier became ineligible to provide
machine
my equipment under Medicare
7 Do not understand the controls or
7 My supplier did not tell me why they
controls hard to use
changed my equipment
96 Other, please tell us what else:
96 Other, please specify:
________________________
________________________
A10.Do you believe that you now have the
CPAP machine that is right for you?
1 Yes
2 No
98 I don’t know
A11.Is using your CPAP machine difficult
or uncomfortable?
1 Yes
2 No (→Skip to A13)
98 I don’t know (→Skip to A13)

A12. In general, how often do you use
your CPAP machine?
1
2
3
4
5

Less than one day or night each
week
1-2 days or nights per week
3-4 days or nights per week
5-6 days or nights per week
Every day or night

CPAP Machine Survey

A13. On the days that you do use your
CPAP machine, for how long do you
use it (out of 24 hours)?

A15a. How many times did you have
these kinds of problems in the
past year?

______ hours per day

1
2
3
4

A14. How reliable is the CPAP machine you
use now? Would you say …
1
2
3
4
98

Very reliable
Somewhat reliable
Somewhat unreliable
Very unreliable
I don’t know

A15. In the past year, did you have any
problems that made you stop using
your CPAP machine or switch to a
different CPAP machine?

One time
2 or 3 times
4 or more times
Don’t recall the exact number of
times

A15b. Can you describe the kind of
problem(s) that you had?
(Please check all that apply.)
1 CPAP machine did not work
2 CPAP accessories did not work
7 Reservoir/humidifier did not work
8 Did not understand the controls
96 Other, please specify:
________________________

1 Yes
2 No (→Skip to SECTION B)
98 I don’t know (→Skip to SECTION B)

CPAP Machine Survey

MEDICAL EXPENSES

B1. In the past year, have you bought any
accessories or parts for your current
CPAP machine with your own money,
or paid for maintenance or repairs
with your own money, because your
insurance did not cover it? (This does
not include any copay or deductible
amounts that are due from you.)
1 Yes
2 No (→Skip to SECTION C)
98 I don’t know (→Skip to SECTION C)

B3.

Thinking about everything you
paid for with your own money in
the past year for your CPAP
machine accessories, parts,
maintenance or repairs not
covered by insurance, how
much did you spend? (This
does not include any copay or
deductible amounts.)

1
2
3
98

Less than $100
$100-$500
$500 or more
I don’t know

B2. In the past year, what parts or service
did you buy with your own money for
your CPAP machine? (Please check
all that apply.)
1 Mask
2 Tubing
3 Power supply or battery
4 Head or chin straps / Headgear
5 Repairs
6 Routine maintenance
7 Filters
8 Humidifier or reservoir
96 Other, please specify:
_________________________

CPAP Machine Survey

YOUR SUPPLIER

C3.

Considering the CPAP machine
you use now, when you asked
your supplier questions, did
you get answers that you could
understand?

1 Yes
2 No (→Skip to C2)
98 I don’t know (→Skip to C2)

1
2
3
4
98

Yes, completely
Yes, somewhat
No
I did not ask any questions
I don’t know

C1a.What kinds of problems did you have
finding a CPAP machine supplier?
(Please check all that apply.)

C4.

Before deciding on the CPAP
machine you use now, did your
supplier tell you as much as
you wanted to know about the
options for your CPAP
machine?

1
2
3
98

Yes, completely
Yes, somewhat
No
I don’t know

C1. Considering the CPAP machine you
use now, did you have any problems
finding an equipment supplier to get
your CPAP machine from?

1 Hard to find a supplier who covered my
area
2 Supplier did not carry what I needed
3 Supplier could not deliver equipment
when I needed it
4 Supplier did not accept Medicare
96 Other, please specify:
__________________________

C2. Considering the CPAP machine you
use now, did you have a choice of
suppliers?
1
2
3
98

Yes, many
Yes, a few
No, only one supplier available
I don’t know

C4a. Before you decided on the
CPAP machine that you use
now, did your supplier tell you
about all the equipment designs
available to you, even those
which the supplier did not have
in stock?
1
2
3
98

Yes, all equipment designs were
explained
No, the supplier only told me what
he/she has in stock
No, I already knew the equipment
designs available to me
I don’t know

CPAP Machine Survey

C5. After you ordered your CPAP
machine, how long did it take to
arrive?
1
2
3
4
98

C7.

When you got the CPAP
machine you use now, what
kind of training or help did the
supplier give you or the person
who takes care of you? Did
he/she … (Please check all that
apply.)

1

Give you written instructions on
how to use the CPAP machine
Show you how to use the CPAP
machine
Choose a safe and convenient
place to store and charge the
CPAP machine
Show you how to clean and
maintain the CPAP machine
Let you practice how to use and
maintain your CPAP machine
while they watched
Gave me the manufacturer’s
customer assistance toll-free
telephone number
Sent someone to my home to
explain how to use it
I did not get any training or help
from my supplier (→Skip to C8)
I don’t know (→Skip to C8)

Next day
Within a week
1-2 weeks later
More than 2 weeks later
I don’t know

C6. How did you get your CPAP
machine?
1 Delivered to my home by my supplier
2 Mailed to my home by my supplier
3 I (or someone on my behalf) picked it up
from my supplier
98 I don’t know
99 Some other way, please specify:
_______________________

2
3

4
5

6

7
8
98

CPAP Machine Survey

C7a. As a result of that training, how
comfortable do you feel using and
maintaining your CPAP machine?
1
2
3
4
5

Very comfortable
Comfortable
Uncomfortable
Very uncomfortable
My comfort level has nothing to do
with the training that my supplier gave
me

C8.

In the 3 months after you got the
CPAP machine you use now, how
often did your supplier send
someone like a nurse or a
respiratory therapist to your
home to check the equipment or
see how well you are doing with
the equipment? (Do not include
times when you called them.)

1
2
3

C9.

Considering the CPAP machine
you use now, how much time
and energy did it take to get the
CPAP machine, accessories,
parts, maintenance and repairs
from your supplier?

1
2
3
4
98

No time and energy
A little time and energy
Some time and energy
A lot of time and energy
I don’t know

C10. Would you recommend this
CPAP machine supplier to a
friend who needed similar
equipment and services?
1
2

Yes
No

Once in the 3 months after you got
the CPAP machine
More than once in the 3 months
after you got the CPAP machine
Not at all in the 3 months after you
got the CPAP machine

CPAP Machine Survey

RECENT EXPERIENCES
Please answer the following
questions about the supplier that
you use most often for your CPAP
machine and accessories.

D1.

During the past six months,
how reliable was your supplier
in making deliveries or repairs?

1
2
3
4

Very reliable
Somewhat reliable
Not reliable at all
Does not apply

D2.

In the past six months, have
you contacted your supplier
with a complaint or a problem?

1
2
98
4

Yes
No (→Skip to D5)
I don’t know (→Skip to D5)
Don’t know how to contact my
supplier (→Skip to D5)

D2a. When you contacted your
supplier, was your complaint or
problem settled to your
satisfaction?
1
2
3
98

D3.

In the past six months, have
you contacted your supplier to
get emergency service or
advice?

1
2
98

Yes
No ( →Skip to D4)
I don’t know (→Skip to D4)

D3a.

In general, how fast did the
supplier respond to your
needs, either by phone or in
person? Would you say …

1
2
3
4
98

Within 1 day
Within 2 days
Within 1 week
Longer than 1 week
I don’t know

D3b.

Were you able to get the
emergency service or advice
you needed?

1
2
98

Yes
No
I don’t know

Yes
No
I am waiting for it to be settled
I don’t know

CPAP Machine Survey

D4.

In the past six months, have
you needed to contact your
supplier after regular business
hours?

1 Yes
2 No (→Skip to D5)
98 I don’t know (→Skip to D5)

D4a.When you contacted your
supplier after business hours,
were you able to get the service
or advice you needed?
1 Yes
2 No
98 I don’t know

D5. Overall, how would you rate the
supplier that you use most?
1
2
3
4
5

Poor
Fair
Good
Very good
Excellent

D6a. Why did you change your CPAP
machine supplier? (Please
check all that apply.)
I moved
Supplier became ineligible to
provide the equipment under
Medicare
Supplier went out of business
3
I was not happy with the quality of
4
service
I was not happy with equipment
5
I was not happy with the choices
6
of equipment or service I could get
I was not happy with the
7
assistance I got in handling the
insurance
Supplier did not provide CPAP
8
machine, accessories or repair
service I needed
9
I changed to an HMO and had to
use a different supplier
96 Other, please specify:
__________________________
1
2

D6. In the past six months, have you
changed your CPAP machine
supplier?
1 Yes
2 No (→Skip to SECTION E)
98 I don’t know (→Skip to SECTION
E)

CPAP Machine Survey

E4.
E. ABOUT YOU
Section E is about you, the person
whose name is on the mailing label of
this survey.
E1.

In general, how would you rate
your overall health?

1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

E2.

1
2
3
4
5

Compared to 1 year ago, how
would you rate your health
now? Would you say …
Much better now
Somewhat better now
About the same
Somewhat worse now
Much worse now

E3. Do you currently live alone?
Yes (→Skip to E5)
1
No
2

1
2
3
4
5
6

Which best describes your
living situation now? (Please
check all that apply.) I live….
With spouse/partner
With parent/step-parent
With child/children
With other relative(s)
With friend
With other person(s) not related to
me

E5.

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

1
2
3
4
5
6

8th grade or less
Some high school but did not graduate
High school graduate or GED
Some college or technical school
College graduate
More than a 4-year college degree

E6.

What was your household’s
annual income during 2009,
before taxes?

1
2

Less than $5,000 ($416 per month)
Between $5,001 and $10,000
($417–$833 per month)
Between $10,001 and $20,000
($834–$1,666 per month)
Between $20,001 and $30,000
($1,667–2,500 per month)
Between $30,001 and $50,000
($2,501–$4,167 per month)
Over $50,000 (over $4,168 per
month)

3
4
5
6

CPAP Machine Survey

E7.

Are you of Hispanic or Latino
origin or descent?

OTHER INFORMATION

1
2

Yes, Hispanic or Latino
No, not Hispanic or Latino

F1.

Please check the correct
statement:

1

I am the person to whom this
survey was addressed (→Skip to
END)
I filled this survey out or helped fill it
out for someone else

E8.

How would you describe your
race? (Please check all that
apply.)

American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific
Islander
White or Caucasian
5
96 Other, please tell us:
________________________
1
2
3
4

2

F2.

How did you help the person
with this survey?

1

I wrote the answers that the person
told me
I answered the questions myself
based on my knowledge of the
person’s condition
Both of the above

2

3

Thank you for completing the survey. Please return the completed survey in the
postage-paid envelope addressed to:
Survey of Medicare Patients
Abt Associates Inc.
55 Wheeler Street,
Cambridge, MA 02138

CPAP Machine Survey

If you have any questions about the survey, please call toll-free 1-888-XXXXXXX.
If you have any questions about Medicare, please visit the website of the
Center for Medicare Services at: http://www.medicare.gov/, or call 1-800MEDICARE.

CPAP Machine Survey

OMB# 0938-NEW
1001

Survey of Medicare
Patients Who Use
a Hospital Bed
The purpose of the study is to learn more about your satisfaction with the
equipment, supplies, and service you receive from your hospital bed
supplier. We also hope to better understand your experiences in obtaining
and using this equipment.

1

Please return by ______________.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-NEW. The time required to complete this information collection is estimated to average 30
minutes per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn:
PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Instructions
The questions in this survey ask about your experiences as a person who
uses a hospital bed.
To complete the survey, please answer the questions by checking the box to the
left of your answer (as shown below). You are sometimes told to skip over some
questions in this survey. When this happens you will see an arrow beside your
response with a note that tells you which question to answer next, like this:
 Yes
 No → Skip to A5
 I don’t know

If there is no arrow next to your response, please proceed to the next question.
Some people might ask someone else (maybe a spouse, child, or friend) to help
them complete this survey. If someone is helping you fill out the survey,
remember that the questions always refer to you and your experience with your
hospital bed.

A.
A1.

USE OF HOSPITAL BEDS
When did you begin using a
hospital bed?
1
2
3
4
5

A2.

2010
2009
2008
Before 2008
I have never used a hospital bed
(Skip to SECTION E on page
10)

1 My condition got better so I
did not need it anymore
2 My condition got worse
3 I was not comfortable in it
5 I did not feel safe in it
6 I just did not like it
7 It was too difficult to use
8 It kept breaking
10 It did not have the features I
needed
96 Other, please specify:
__________________________

When you first began using a
hospital bed, how long did you
expect to use it?
1
2
3
4
98

A3.

A3a. Why did you stop using your
hospital bed? (Please check all
that apply and then skip to
SECTION E on page 10)

Less than 1 month
2 to 6 months
More than 6 months
Forever
I don’t know

YOUR CURRENT USE OF HOSPITAL BED
A4.

Do you use a hospital bed now?
This includes using a hospital bed
all of the time or just occasionally.

When did you first get the hospital
bed you use now?
1 Less than 6 months ago
2 6-12 months ago
3 More than 12 months ago

1 Yes (→ Skip to A4)
2 No, I no longer use a hospital bed
A5.

Does someone regularly help you
use your hospital bed (for
example, a relative, friend or home
health aide)?
1 Yes
2 No

Hospital Bed Survey

A6.

1
2
3
98

Did a doctor or another medical
person like a nurse or
physical/occupational therapist
ever explain the following to you
(Please check all that apply):
Why you needed to have a hospital
bed
The different types of hospital beds
and controls
None of these things were explained
by a medical person
I don’t know or don’t recall if a medical
person explained anything to me

A8.

Have you had more than one
hospital bed in the past year?

1
2
98

No (→ Skip to SECTION B)
Yes, I changed my hospital bed
I don’t know (→ Skip to SECTION B)

A8a. Why did you make this (these)
change(s)? (Please check all that
apply.)
1

2
A7.

1
2
3
4
98

When was the last time you
discussed your needs or issues
related to your medical bed with a
doctor or another medical person
like a nurse or physical /
occupational therapist?

3

Within the last 6 months
Between 6 months and 1 year ago
Between 1 and 3 years ago
More than 3 years ago
I don’t know

6

4
5

7
96

Hospital bed needed to be
replaced because the original
one did not work
My medical condition changed,
so I needed something different
Found a new hospital bed that
was better for me
Found new features / controls
that were better for me
Doctor/ health care provider
prescribed a different type of
hospital bed
My supplier became ineligible to
provide my equipment under
Medicare
My supplier did not tell me why
they changed my equipment
Other, please specify:

A9.

Do you believe that you now
have the hospital bed that is
right for you?

1
2
98

Yes
No
I don’t know

Hospital Bed Survey

A10. Is using your hospital bed difficult
or uncomfortable?
1
2
98

A12.

Yes
No (→Skip to A11)
I don’t know (→Skip to A11)

______ hours per day
A13.

A10a. What is it about your hospital bed that
makes it difficult or uncomfortable for 1
you to use? (Please check all that
2
apply.)
3
4
It is difficult for me to sit up
1
98
It is difficult for me to reach controls

2

It is difficult for me to shift my weight
for pressure relief
It is difficult for me to transfer in and
4
out of the hospital bed easily
I cannot lie comfortably in it
5
The tray or other attachments are
6
hard to adjust or use
It takes up a lot of space
8
96 Other, please tell us what else:
_______________________

On the days that you are in your
hospital bed, for how long do you
use it (out of 24 hours)?

How reliable is the hospital bed
you use now? Would you say …
Very reliable
Somewhat reliable
Somewhat unreliable
Very unreliable
I don’t know

3

A11. In general, how often do you use your
hospital bed?
1
2
3
4
5

Less than one day or night per week
1-2 days or nights per week
3-4 days or nights per week
5-6 days or nights per week
Every or night day

A14.

In the past year, did you have
any problems that made you
stop using a hospital bed or
switch to a different hospital
bed?

1
2
98

Yes
No (→ Skip to SECTION B)
I don’t know (→ Skip to
SECTION B)

A14a. How many times did you have
these kinds of problems in the
past year?
1
2
3
4

One time
2 or 3 times
4 or more times
Don’t recall the exact number of
times

Hospital Bed Survey

A14b. Can you describe the kind of
problem(s) that you had? (Please
check all that apply.)

MEDICAL EXPENSES

B1.

In the past year, have you bought
any accessories or parts for your
current hospital bed with your
own money, or paid for
maintenance or repairs with your
own money, because your
insurance did not cover it? (This
does not include the copay
amounts that are due from you.)

Hospital bed did not work
1
Hospital bed adjustments did not work
2
96 Other, please specify:
_________________________

1
2
98
B2.

Yes
No (→ Skip to SECTION C)
I don’t know (→ Skip to SECTION C)
In the past year, what parts or
service did you buy with your
own money for your hospital
bed? (Please check all that
apply.)

1
Mattress
Bed board
2
3
Bed cradle
Bed side rails
4
Safety enclosure frame
5
Trapeze bars
6
Repairs
7
Routine maintenance
8
Other, please specify:
96
_______________________

Hospital Bed Survey

B3.

Thinking about everything you paid
for with your own money in the past
year for your hospital bed
accessories, parts, maintenance or
repairs not covered by insurance,
how much did you spend on your
current hospital bed? (This does
not include any copay or deductible
amounts.)
1
2
3
98

Less than $100
$100-$500
$500 or more
I don’t know

YOUR SUPPLIER

C1.

Considering the hospital bed
you use now, did you have any
problems finding an equipment
supplier to get your hospital
bed from?

1
2
98

Yes
No (→Skip to C7)
I don’t know (→Skip to C7)

C1a. What kinds of problems did you
have finding a hospital bed
supplier? (Please check all that
apply.)
Hard to find a supplier who
covered my area
Supplier did not carry what I
2
needed
3
Supplier could not deliver
equipment when I needed it
Supplier did not accept Medicare
4
Other, please describe:
96
_______________________
1

C2.

1
2
3
98

Considering the hospital bed you
use now, did you have a choice
of suppliers?
Yes, many
Yes, a few
No, only one supplier available
I don’t know

Hospital Bed Survey

C3.

Considering the hospital bed you
use now, when you asked your
supplier questions, did you get
answers that you could
understand?

1
2
3
4
98

Yes, completely
Yes, somewhat
No
I did not ask any questions
I don’t know

C4.

Before deciding on the hospital bed
you use now, did your supplier tell
you as much as you wanted to know
about the options for your hospital
bed?

1
2
3
98

Yes, completely
Yes, somewhat
No
I don’t know

C5.

After you ordered your hospital
bed, how long did it take to
arrive?

1
2
3
4
98

Same day
Next day
Within a week
More than 1 week later
I don’t know

C6.

How did you get your hospital
bed?

1

Delivered or shipped to my home by
my supplier
I (or someone on my behalf) picked it
up from my supplier
I don’t know
Some other way, please specify:
_________________________

2
98
96

C4a. Before you decided on the hospital
bed that you use now, did your
supplier tell you about all the
equipment designs available to
you, even those which the supplier
did not have in stock?
1
2
3
98

Yes, all equipment designs were
explained
No, the supplier only told me what
he/she has in stock
No, I already knew the equipment
designs available to me
I don’t know

Hospital Bed Survey

C7.

When you got your the hospital
bed you use now, what kind of
training or help did the supplier
give you or the person who takes
care of you? Did he/she…
(Please check all that apply.)

1

Give you written instructions on how
to use the hospital bed
Show you how to use the hospital
bed
Choose a safe and convenient place
to place the hospital bed
Show you how to clean and maintain
the hospital bed
Show you how to use the hospital
bed safely
Let you practice how to use and
maintain your hospital bed while they
watched
Give you the manufacturer’s
customer assistance toll-free
telephone number
I did not get any training or help from
my supplier (→Skip to C8)
I don’t know (→Skip to C8)

2
3
4
5
6

7

8
98

C7a. As a result of that training, how
comfortable do you feel using and
maintaining your hospital bed?
1
2
3
4
5

C8.

Considering the hospital bed
you use now, how much time
and energy did it take to get the
hospital bed, accessories, parts,
maintenance and repairs from
your supplier?

1
2
3
4
98

No time and energy
A little time and energy
Some time and energy
A lot of time and energy
I don’t know

C9.

Overall, how would you rate the
supplier that you use most?

1
2
3
4
5

Poor
Fair
Good
Very good
Excellent

C10. Would you recommend this
hospital bed supplier to a friend
who needed similar equipment
and services?
1
2

Yes
No

Very comfortable
Comfortable
Uncomfortable
Very uncomfortable
My comfort level has nothing to do with
the training that my supplier gave me
Hospital Bed Survey

D. RECENT EXPERIENCES
Please answer the following questions
about the supplier that you use most
often if you use more than one supplier
for your walker and accessories.
D1.

During the past six months, how
reliable was your supplier in
making deliveries or repairs?

1
2
3
99

Very reliable
Somewhat reliable
Not reliable at all
Does not apply

D2.

In the past six months, have
you contacted your supplier
with a complaint or a problem?

1
2
98
4

Yes
No (→Skip to D5)
I don’t know (→Skip to D5)
I don’t know how to contact my
supplier (→Skip to D5)

D2a. When you contacted your
supplier, was your complaint or
problem settled to your
satisfaction?
1
2
3
98

D3.

In the past six months, have
you contacted your supplier to
get emergency service or
advice?

 Yes
2 No (→ Skip to D5)
98 I don’t know (→ Skip to D5)

D3a. In general, how fast did the
supplier respond to your needs,
either by phone or in person?
Would you say…
1 Within 1 day
2 Within 2 days
3 Within 1 week
4 Longer than 1 week
98 I don’t know

D3b. Were you able to get the
emergency service or advice you
needed?
1
2
98

Yes
No
I don’t know

Yes
No
I am waiting for it to be settled
I don’t know

Hospital Bed Survey

D4.

1
2
98

In the past six months, have you
needed to contact your supplier
after regular business hours?
Yes
No (→ Skip to D5)
I don’t know (→ Skip to D5)

D4a. When you contacted your supplier
Question the requirement for this
after business hours, were you
able to get the service or advice
you needed?
1
2
98

Yes
No
I don’t know

D5.

In the past six months, have you
changed your hospital bed
supplier?

1
2

Yes
No (→ Skip to SECTION E on
page 10)
I don’t know (→ Skip to SECTION
E on page 10)

98

D5a. Why did you change your
hospital bed supplier? (Please
check all that apply.)
I moved
Supplier no longer accepted
Medicare
3 Supplier went out of business
4 I was not happy with the quality of
service
5 I was not happy with equipment
6 I was not happy with the choices of
equipment or service I could get
7 I was not happy with the assistance
I got in handling the insurance
8 Supplier did not provide hospital
bed, accessories or repair service I
needed
9 I changed to an HMO and had to
use a different supplier
10 Supplier became ineligible to
provide the equipment under
Medicare
96 Other, please specify:
_________________________
1
2

Hospital Bed Survey

ABOUT YOU
Section E is about you, the person
whose name is on the mailing
label of this survey.

E1.

In general, how would you rate
your overall health?

1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

E2.

Compared to 1 year ago, how
would you rate your health now?
Would you say…

1
2
3
4
5

Much better now
Somewhat better now
About the same
Somewhat worse now
Much worse now

E3.

Do you currently live alone?

1
2

Yes (→Skip to E5)
No

E4.

Which best describes your living
situation now? (Please check all
that apply.) I live …

1
2
3
4
5
6

With spouse/partner
With parent/step-parent
With child/children
With other relative(s)
With friend
With other person(s) not related to
me

E5.

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

1
2

8th grade or less
Some high school but did not
graduate
High school graduate or GED
Some college or technical school
College graduate
More than a 4-year college degree

3
4
5
6
E6.

What was your household’s
annual income during 2006
before taxes?

1
2

Less than $5,000 ($416 per month)
Between $5,001 and $10,000
($417–$833 per month)
Between $10,001 and $20,000
($834–$1,666 per month)
Between $20,001 and $30,000
($1,667–2,500 per month)
Between $30,001 and $50,000
($2,501–$4,167 per month)
Over $50,000 (over $4,168 per
month)

3
4
5
6

Hospital Bed Survey

E7.

Are you of Hispanic or Latino
origin or descent?

1
2

Yes, Hispanic or Latino
No, not Hispanic or Latino

E8.

How would you describe your
race? (Please check all that apply.)

American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific
Islander
5 White or Caucasian
96 Other, please tell us:
_______________________
1
2
3
4

F. OTHER INFORMATION
F1.

Please check the correct
statement:

1

I am the person to whom this
survey was addressed (→Skip to
END)
I filled this survey out or helped fill it
out for someone else

2

F2.

How did you help the person with
this survey?

1

I wrote the answers that the person
told me
I answered the questions myself
based on my knowledge of the
person’s condition
Both of the above

2

3

Thank you for completing the survey. Please return the completed survey in
the postage-paid envelope addressed to:

CMS Survey of Medicare Beneficiaries
Abt Associates Inc.
55 Wheeler Street,
Cambridge, MA 02138

If you have any questions about the survey, please call toll-free 1-888XXX-XXXX.
If you have any questions about Medicare, please visit the website of the
Center for Medicare Services at: http://www.medicare.gov/, or call 1-800MEDICARE.
Hospital Bed Survey

OMB# 0938-XXX
1001

Survey of Medicare
Patients Who Use a Power
Wheelchair
The purpose of the study is to learn more about your satisfaction with the
equipment, supplies, and service you receive from your oxygen (or other
durable medical equipment) supplier. We also hope to better understand
your experiences in obtaining and using this equipment.

1

Please return by ______________.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-NEW. The time required to complete
this information collection is estimated to average 30 minutes per response, including the
time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to:
CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

Abt Associates, Inc.
CMS 10197-BOS

Beneficiary Oxygen Survey

Instructions
The questions in this survey ask about your experiences as a person who uses a power
wheelchair.
To complete the survey, please answer the questions by checking the box to the left of your
answer (as shown below). You are sometimes told to skip over some questions in this survey.
When this happens you will see an arrow beside your response with a note that tells you which
question to answer next, like this:
 Yes
 No → Skip to A5
 I don’t know

USE OF POWER WHEELCHAIRS

A1.

When did you begin using a power
wheelchair?

1

2010
Abt Associates, Inc.
CMS 10197-BOS

Beneficiary Oxygen Survey

2
3
4
5

2009
2008
Before 2008
I have never used a power wheelchair
(Skip to SECTION E on page 11)

A2.

When you first began using a power
wheelchair, how long did you expect
to use it?

1
2
3
4
98

Less than 1 month
1 to 6 months
More than 6 months
Forever
I don’t know

A3.

Do you use a power wheelchair now?
This includes using a power
wheelchair all of the time or just
occasionally.

1
2

Yes (→Skip to A4)
No, I have never used a power
wheelchair

A3a. If you are no longer using your
power wheelchair, why did you
stop? (Please check all that apply
and then skip to SECTION E on
page 11.)
My condition got better so I did not
need it anymore
2 My condition got worse so I couldn’t
use it anymore
3 I was embarrassed to use it
4 I was not comfortable sitting in it
5 I did not feel safe driving it
6 I just did not like using it
7 It was too difficult to use
8 It kept breaking down
9 I had no place to charge it and/or
store it
10 It did not have the features I needed
96 Other, please specify:
___________________________
1

USE OF YOUR CURRENT POWER
WHEELCHAIR
A4. When did you first get the power
wheelchair you use now?
1
2
3

Less than 6 months ago
6-12 months ago
More than 12 months ago

A5. Did you get your current power
wheelchair while you were in a
nursing home or hospital?
1
2

Yes
No

Power Wheelchair Survey

A6.

Does someone regularly help you
use your power wheelchair (e.g. a
relative, friend or home health aide)?

1
2

Yes
No

A7.

Did a doctor or another medical
person like a nurse or
physical/occupational therapist ever
explain the following to you (Please
check all that apply): why you
needed to use a power wheelchair?

1
2

3
98

A9. Have you had more than one power
wheelchair in the past year or
changed accessories (for example,
controls, cushion) in the past year?
1
2

Why you needed to use a power
wheelchair
The different types of power
wheelchairs, control options, and
accessories that exist
None of these things were explained by
a medical person
I don’t know or don’t recall if a medical
person explained anything to me

A8.

When was the last time you discussed
your needs or issues related to your
power wheelchair with a doctor or
another medical person like a nurse or
physical/ occupational therapist?

1
2
3
4
98

Within the last 6 months
Between 6 months and 1 year ago
Between 1 and 3 years ago
More than 3 years ago
I don’t know

3
98

No (→Skip to A10)
Yes, I changed my power
wheelchair
Yes, I changed or added
accessories
I don’t know (→Skip to A10)

A9a. Why did you make this (these)
change(s)? (Please check all that
apply.)
Wheelchair needed to be replaced
because the original one did not
work
2 My medical condition changed, so I
needed something different
3 Found a new wheelchair that was
better for me
4 Found new features/accessories
that were better for me
5 Doctor or health care provider
prescribed a different type of
wheelchair or different accessories
6 My supplier did not tell me why they
changed my equipment
6 My supplier became ineligible to
provide my equipment under
Medicare
96 Other, please specify:
____________________________
1

Power Wheelchair Survey

A10. Do you believe that you now have the
power wheelchair that is right for
you?
1
2
98

Yes
No
I don’t know

A11. Is using your power wheelchair
difficult or uncomfortable?
1
2
98

Yes
No (→Skip to A12)
I don’t know (→Skip to A12)

A11a. What is it about your power
wheelchair that makes it difficult or
uncomfortable to use? (Please
check all that apply.)
Battery range not sufficient for daily
activities
2 Not enough power to get over
barriers such as ramps, thresholds
and curbs
3 Not enough speed to safely cross
the street during a traffic light
change
4 It is difficult to shift my weight for
pressure relief
5 It is difficult to use the chair easily
inside my home
6 It is difficult to use the chair easily
outside of my home
7 It is difficult to transport the chair to
where I want to go
8 It is difficult sit comfortably in it for
a long time
9 It is difficult transfer in and out of
the wheelchair easily
10 It is too heavy and cumbersome to
use
11 I have trouble charging it
96 Other, please tell us what else:
___________________________
1

Power Wheelchair Survey

A12. In general, how often do you use
your power wheelchair?
1
2
3
4
5

A16a. How many times did you have
these kinds of problems in the
past year?

Less than one day a week
1-2 days per week
3-4 days per week
5-6 days per week
Every day

1
2
3

One time
2 or 3 times
4 or more times

A16b. Can you describe the kind of
problem(s) that you had? (Please
check all that apply.)

A13. On the days that you do use your
power wheelchair, for how long do
you use it? (out of 24 hours in a
day)?

1 Batteries did not work
2 Motor did not work
3 Controls or joystick did not work
96 Other, please specify:
_________________________

______ hours per day

A14. How reliable is the power wheelchair
B.
you use now? Would you say…
1
2
3
4
98

Very reliable
Somewhat reliable
Somewhat unreliable
Very unreliable
I don’t know

A15. In the past year, did you have any
problems that made you stop using
your power wheelchair or switch to a
different power wheelchair?
1
2
98

Yes
No (→Skip to SECTION B)
I don’t know (→Skip to SECTION B)

Power Wheelchair Survey

MEDICAL EXPENSES
B1.

In the past year, have you bought any
accessories or parts for your current
power wheelchair with your own
money, or paid for maintenance or
repairs with your own money
because your insurance did not
cover it? (This does not include any
copay or deductible amounts that are
due from you.)

1
2
98

Yes
No (→Skip to SECTION C)
I don’t know (→Skip to SECTION C)

B2.

In the past year, what parts or service
did you buy with your own money for
your current power wheelchair?
(Please check all that apply.)

B3. Thinking about everything you paid
for with your own money in the past
year for your wheelchair
accessories, parts, maintenance or
repairs not covered by insurance,
how much did you spend on your
current power wheelchair? (This
does not include any copay or
deductible amounts.)
1
2
3
4
98

Less than $100
$100-$500
$500 or $1,000
$1,000- $2,000
I don’t know

1
Seat or back cushions
Tires
2
Batteries
3
Motors
4
5
Crutch holder
Lap tray
6
Repairs
7
Routine maintenance
8
96 Other, please specify:
_________________________

Power Wheelchair Survey

YOUR SUPPLIER

C1.

Considering the power wheelchair
you use now, did you have any
problems finding an equipment
supplier to get your wheelchair from?

1
2
3
4
98

1 Yes
2 No (→Skip to C2)
98 I don’t know (→Skip to C2)
C1a. What kinds of problems did you have
finding a power wheelchair supplier?
(Please check all that apply.)
1 Hard to find a supplier who covered
my area
2 Supplier did not carry what I
needed
3 Supplier could not deliver
equipment when I needed it
4 Supplier did not accept Medicare
96 Other, please specify:
__________________________

C2.

Considering the power wheelchair
you use now, did you have a choice
of suppliers?
1
2
3
98

Yes, many
Yes, a few
No, only one supplier available
I don’t know

C3. Considering the power
wheelchair you use now, when
you asked your supplier
questions, did you get answers
that you could understand?
Yes, completely
Yes, somewhat
No
I did not ask any questions
I don’t know

C4. Before deciding on the power
wheelchair you use now, did your
supplier tell you as much as you
wanted to know about the options
for your power wheelchair?
1
2
3
98

Yes, completely
Yes, somewhat
No
I don’t know

C4a. Before you decided on the power
wheelchair that you use now, did
your supplier tell you about all the
equipment designs available to you,
even those which the supplier did
not have in stock?
1
2
3
98

Yes, all equipment designs were
explained
No, the supplier only told me what
he/she has in stock
No, I already knew the equipment
designs available to me
I don’t know

Power Wheelchair Survey

C5.

After you ordered your power
wheelchair, how long did it take to
arrive?

1
2
3
4
5
98

less than 2 weeks
2 weeks to 1 month
1 to 2 months
2 to 3 months
More than 3 months
I don’t know

C6.

How did you get the power wheelchair
you use now?

C7. When you got the power wheelchair
you use now, what kind of training
or help did the supplier give you or
the person who cares for you?
Did he/she … (Please check all that
apply.)
1
2
3
4

1
2
3
4
98
96

Delivered to my home by my supplier
Mailed/shipped to my home by my supplier
I (or someone on my behalf) picked it up
from my supplier
I picked it up at a seating clinic or
rehabilitation center
I don’t know
Some other way, please specify:

5
6

7
8
98

Give you written instructions on how to
use the power wheelchair
Show you how to drive the power
wheelchair
Show you how to charge your chair
battery
Show you how to clean and maintain
the power wheelchair
Show you how to use the power
wheelchair safely
Let you practice how to use and
maintain your power wheelchair while
they watched
Gave me the manufacturer’s customer
assistance toll-free telephone number
I did not get any training or help from
my supplier (→ Skip to C8)
I don’t know (→ Skip to C8)

C7a. As a result of that training, how
comfortable do you feel using and
maintaining your power
wheelchair?
1
2
3
4
5

Very comfortable
Comfortable
Uncomfortable
Very uncomfortable
My comfort level has nothing to do
with the training that my supplier
gave me

Power Wheelchair Survey

C8.

1
2
3

C9.

1
2
3
4
98

In the 3 months after you got the
power wheelchair you use now, how
often did your supplier send
someone to your home to check the
equipment or see how well you are
doing with the equipment? (Do not
include times when you called them.)
Once in the 3 months after you got the
power wheelchair
More than once in the 3 months after
you got the power wheelchair
Not at all in the 3 months after you got
the power wheelchair

Considering the power wheelchair
you use now, how much time and
energy did it take to get the power
wheelchair, accessories, parts,
maintenance and repairs from the
supplier?
No time and energy
A little time and energy
Some time and energy
A lot of time and energy
I don’t know

C10. Considering the power wheelchair
you use now, do you get your
accessories, parts, maintenance
and repairs from more than one
equipment supplier?
1 Yes
2 No
98 I don’t know

C11. Overall, how would you rate the
supplier that you use most?
1
2
3
4
5

Poor
Fair
Good
Very good
Excellent

C12. Would you recommend this power
wheelchair supplier to a friend who
needed similar equipment and
services?
1
2

Yes
No

Power Wheelchair Survey

RECENT EXPERIENCES

D3. In the past six months, have you
contacted your supplier to get
emergency service or advice?
1 Yes
2 No (→Skip to D5)
98 I don’t know (→Skip to D5)

If you use more than one supplier
for your wheelchair and
accessories, please answer the
following questions about the
supplier that you use most often.
D1. During the past six months, how
reliable was your supplier in making
repairs, if needed?
1
2
3
99

Very reliable
Somewhat reliable
Not reliable at all
Does not apply

D2. In past six months, have you
contacted your supplier with a
complaint or a problem?
1
2
98
4

Yes
No (→Skip to D3)
I don’t know (→Skip to D3)
Don’t know how to contact my
supplier (→Skip to D3)

D3a. In general, how fast did the
supplier respond to your needs,
either by phone or in person?
Would you say …
1
2
3
4
98

Within 1 day
Within 2 days
Within 1 week
Longer than 1 week
I don’t know

D3b. Were you able to get the
emergency service or advice you
needed?
1 Yes
2 No
98 I don’t know

D2a. When you contacted your
supplier, was your complaint or
problem settled to your
satisfaction?
1
2
3
98

Yes
No
I am waiting for it to be settled
I don’t know

Power Wheelchair Survey

D4. In the past six months, did you
need to contact your supplier
after regular business hours?

D5a. Why did you change your power
wheelchair supplier? (Please
check all that apply.)

1 Yes
2 No (→Skip to D5)
98 I don’t know (→Skip to D5)

1
2

D4a. When you contacted your supplier
after business hours, were you able
to get the service or advice you
needed?
1 Yes
2 No
98 I don’t know
D5. In the past six months, have you
changed your power wheelchair
supplier?
1
2
98

Yes
No (→Skip to SECTION E on page
11)
I don’t know (→Skip to SECTION E
on page 11)

I moved
Supplier no longer accepted
Medicare
3 Supplier went out of business
4 I was not happy with the quality of
service
5 I was not happy with equipment
6 I was not happy with the choices of
equipment or service I could get
7 I was not happy with the assistance
I got in handling the insurance
8 Supplier did not provide power
wheelchair, accessories or repair
service I needed
9 I changed to an HMO and had to
use a different supplier
10 Supplier became ineligible to
provide the equipment under
Medicare
96 Other, please describe:
____________________________

Power Wheelchair Survey

ABOUT YOU
E4.

Section E is about you, the
person whose name is on the
mailing label of this survey.
E1.

In general, how would you rate your
overall health?

1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

E2.

Compared to 1 year ago, how would
you rate your health now? Would
you say…

1
2
3
4
5

Much better now
Somewhat better now
About the same
Somewhat worse now
Much worse now

Which best describes your living
situation now? (Please check all
that apply.)
I live ….
1 With spouse/partner
2 With parent/step-parent
3 With child/children
4 With other relative(s)
5 With friend
6 With other person(s) not related to
me
E5.

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

1
2

8th grade or less
Some high school but did not
graduate
High school graduate or GED
Some college or technical school
College graduate
More than a 4-year college degree

3
4
5
6

E3. Do you currently live alone?
1 Yes (→Skip to E5)
2 No

Power Wheelchair Survey

E6.

1
2
3
4
5
6

What was your household’s
annual income during 2006
before taxes?

OTHER INFORMATION

Less than $5,000 ($416 per month)
Between $5,001 and $10,000
($417–$833 per month)
Between $10,001 and $20,000
($834–$1,666 per month)
Between $20,001 and $30,000
($1,667–2,500 per month)
Between $30,001 and $50,000
($2,501–$4,167 per month)
Over $50,000 (over $4,168 per
month)

1 I am the person to whom this survey
was addressed (→Skip to END)
2 I filled this survey out or helped fill it
out for someone else

F1. Please check the correct statement:

E7.

Are you of Hispanic or Latino
origin or descent?

1
2

Yes, Hispanic or Latino
No, not Hispanic or Latino

E8.

How would you describe your race?
(Please check all that apply.)

F2. How did you help the person with
this survey?
1 I wrote the answers that the person
told me
2 I answered the questions myself
based on my knowledge of the
person’s condition
3 Both of the above

American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific
Islander
5 White or Caucasian
96 Other, please tell us:
________________________

1
2
3
4

Power Wheelchair Survey

Thank you for completing the survey. Please return the completed survey in
the postage-paid envelope addressed to:
Survey of Medicare Patients
Abt Associates Inc.
55 Wheeler Street,
Cambridge, MA 02138

If you have any questions about the survey, please call toll-free
1-888-XXX-XXXX.
If you have any questions about Medicare, please visit the website of the
Center for Medicare Services at: http://www.medicare.gov/, or call
1-800-MEDICARE.

Power Wheelchair Survey

OMB# 0938-XXX
1001

Survey of
Medicare Patients
Who Use a Walker
The purpose of the study is to learn more about your satisfaction with the
equipment, supplies, and service you receive from your walker supplier. We
also hope to better understand your experiences in obtaining and using this
equipment.

1

Please return by ______________.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-NEW. The time required to complete this information collection is estimated to average 30
minutes per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn:
PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Instructions
The questions in this survey ask about your experiences as a person who
uses a walker.
To complete the survey, please answer the questions by checking the box to the
left of your answer (as shown below). You are sometimes told to skip over some
questions in this survey. When this happens you will see an arrow beside your
response with a note that tells you which question to answer next, like this:
 Yes
 No → Skip to A5
 I don’t know

If there is no arrow next to your response, please proceed to the next question.
Some people might ask someone else (maybe a spouse, child, or friend) to help
them complete this survey. If someone is helping you fill out the survey,
remember that the questions always refer to you and your experience with your
walker.

Walker Survey

USE OF WALKERS

A1.

When did you begin using a walker?

1
2
3
4
5

2010
2009
2008
Before 2008
I have never used a walker (Skip to
SECTION E on page 11)

A2.

When you first began using a
walker, how long did you expect to
use it?

1
2
3
4
98

Less than 1 month
1 to 6 months
More than 6 months
Forever
I don’t know

A3.

Do you use a walker now? This
includes using a walker all of the
time or just occasionally.

A4. When did you first get the walker
you use now?

Yes (→ Skip to A4)
No, I no longer use a walker

1
2
3

1
2

A3a. Why did you stop using your
walker? (Please check all that
apply and then skip to SECTION
E on page 10.)
My condition got better so I did not
need it anymore
2 My condition got worse so I
couldn’t use it anymore
3 I was embarrassed to use it
4 I was not comfortable using it
5 I did not feel safe using it
6 I just did not like using it
7 It was too difficult to use
8 It kept breaking
9 It was not the type of walker I
needed
96 Other, please specify:
________________________
1

YOUR CURRENT USE OF WALKER

Less than 6 months ago
6-12 months ago
More than 12 months ago

A5. Did you get your current walker
while you were in a nursing
home or hospital?
1
2

Yes
No

Walker Survey

A6.

Does someone regularly help you
use your walker (for example, a
relative, friend or home health aide)?

1
2

Yes
No

A7.

Did a doctor or another medical
person like a nurse or
physical/occupational therapist ever
explain the following to you (Please
check all that apply):

1
2
3
98

A8.

1
2
3
4
98

Why you needed to use a walker
The different types of walkers and
accessories that exist
None of these things were explained by
a medical person
I don’t know or don’t recall if a medical
person explained anything to me

When was the last time you
discussed your mobility needs or
issues related to your walker with a
doctor or another medical person
like a nurse or physical/occupational
therapist?
Within the last 6 months
Between 6 months and 1 year ago
Between 1 and 3 years ago
More than 3 years ago
I don’t know

A9. Have you had more than one
walker in the past year, or
changed accessories (e.g.
glides, basket) in the past year?
(Please check all that apply.)
1
2
3
98

No (→Skip to A10)
Yes, I changed my walker
Yes, I changed or added
accessories
I don’t know (→Skip to A10)

A9a. Why did you make this (these)
change(s)? (Please check all that
apply.)
1

2
3
4
5

6

7
96

Walker needed to be replaced
because the original one did not
work
My medical condition changed, so I
needed something different
Found a new walker that was better
for me
Found new features/accessories
that were better for me
Doctor or health care provider
prescribed a different walker or
different accessories
My supplier became ineligible to
provide my equipment under
Medicare
My supplier did not tell me why they
changed my equipment
Other, please specify:
_______________________

Walker Survey

A10. Do you believe that you now have
the walker that is right for you?
1
2
98

Yes
No
I don’t know

A11. Is using your walker difficult or
uncomfortable?
1
2
98

Yes
No (→Skip to A13)
I don’t know (→Skip to A13)

A12. In general, how often do you use
your walker?
1
2
3
4
5

Less than one day a week
1-2 days per week
3-4 days per week
5-6 days per week
Every day

A13. On the days that you do use your
walker, how many times per day
do you use it?
______ times per day

A11a. What is it about your walker that
makes it difficult or uncomfortable
to use? (Please check all that
apply.)
1
2
3
4
5
6
7
96

It is difficult to support myself with my
walker
It is difficult to walk with my walker
It is difficult to use the walker inside my
home
It is difficult to use the walker outside of
my home
It is difficult to put the walker in a
car/taxi to go places
It is difficult to get up from a sitting
position with my walker
Walker is too heavy and cumbersome
Other, please tell us what else:

_________________________

A14. How reliable is the walker you
use now? Would you say …
1
2
3
4
98

Very reliable
Somewhat reliable
Somewhat unreliable
Very unreliable
I don’t know

A15. In the past year, did you have
any problems that made you
stop using your walker or switch
to a different walker instead?
1 Yes
2 No (→Skip to SECTION B)
98 I don’t know (→Skip to SECTION B)

________________________

Walker Survey

A15a. How many times did you have these
kinds of problems in the past year?
1
2
3
4

MEDICAL EXPENSES

B1.

In the past year, have you
bought any accessories or parts
for your current walker with
your own money, or paid for
maintenance or repairs with
your own money, because your
insurance did not cover it? (This
does not include any copay or
deductible amounts that are due
from you.)

1
2
98

Yes
No (→Skip to SECTION C)
I don’t know (→Skip to SECTION C)

B2.

In the past year, what parts or
service did you buy with your
own money for your walker?
(Please check all that apply.)

One time
2 or 3 times
4 or more times
Don’t recall the exact number of times

A15b. Can you describe the kind of
problem(s) that you had? (Please
check all that apply.)
1
2
3
4
5
6
7
8
96

The walker collapsed
The wheels wouldn’t turn or would stick
The walker glides cracked or fell off
The walker wouldn’t easily fit through a
doorway
It was difficult to move the walker
around furniture
It was difficult to move the walker in the
bathroom
It was difficult to the walker lift up or
down over roadside curbs
It was difficult to move the walker up or
down stairs
Other, please specify:
________________________

1
Glide covers or skis
Hook (for example, to hang a bag)
2
3
Bag or tote
Basket
4
Tray
5
Repairs
6
Routine maintenance
7
96 Other (please specify)
___________________________

Walker Survey

B3.

1
2
3
98

Thinking about everything you paid
for with your own money in the past
year for your walker accessories,
parts, maintenance or repairs not
covered by insurance, how much did
you spend on your current walker?
(This does not include any copay or
deductible amounts.)
Less than $100
$100-$500
$500 or more
I don’t know

YOUR SUPPLIER

C1.

Considering the walker you use
now, did you have any problems
finding an equipment supplier
to get your walker from?

1
2
98

Yes
No (→Skip to C2)
I don’t know (→Skip to C2)

C1a. What kinds of problems did you
have finding a walker supplier?
(Please check all that apply.)
1
2
3
4
5
96

I didn’t know how to find a supplier
Hard to find a supplier who
covered my area
Supplier did not carry what I needed
Supplier could not deliver
equipment when I needed it
Supplier did not accept Medicare
Other, please specify:

C2.

Considering the walker you use
now, did you have a choice of
suppliers?

1
2
3
98

Yes, many
Yes, a few
No, only one supplier available
I don’t know

Walker Survey

C3.

Considering the walker you use
now, when you asked your supplier
questions, did you get answers that
you could understand?

1
2
3
4
98

Yes, completely
Yes, somewhat
No
I did not ask any questions
I don’t know

C4.

Before deciding on the walker you
use now, did your supplier tell you
as much as you wanted to know
about the options for your walker?

1
2
3
98

Yes, completely
Yes, somewhat
No
I don’t know

C4a.

Before you decided on the walker
that you use now, did your supplier
tell you about all the equipment
designs available to you, even those
which the supplier did not have in
stock?

1

Yes, all equipment designs were
explained
No, the supplier only told me what
he/she has in stock
No, I already knew the equipment
designs available to me
I don’t know

2
3
98

C5.

After you ordered your walker,
how long did it take to arrive?

1
2
3
4
98

Next day
Within a week
1-2 weeks later
More than 2 weeks later
I don’t know

C6.

How did you get your walker?

Delivered to my home by my
supplier
2
Mailed/shipped to my home by my
supplier
I (or someone on my behalf)
3
picked it up from my supplier
I picked it up at a clinic or
5
rehabilitation center
98 I don’t know
96 Some other way, please specify:
________________________

1

Walker Survey

C7. When you got the walker you C8.
use now, what kind of training
or help did the supplier give you
or the person who takes care of
you? Did he/she … (Please
check all that apply.)
1
1 Give you written instructions on 2
how to use the walker
3
2 Show you how to use the walker 4
safely
98
3 Show you how to take care of the
walker
4 Let you practice how to use your
walker while they watched
5 Give you the manufacturer’s
customer assistance toll-free
telephone number
6 I did not get any training or help
from my supplier (→Skip to C8)
98 I don’t know (→Skip to C8)
C7a.

1
2
3
4
5

As a result of that training, how
comfortable do you feel using and
maintaining your walker?
Very comfortable
Comfortable
Uncomfortable
Very uncomfortable
My comfort level has nothing to do with
the training that my supplier gave me

Considering the walker you use
now, how much time and energy did
it take to get the walker,
accessories, parts, maintenance and
repairs from your supplier?
No time and energy
A little time and energy
Some time and energy
A lot of time and energy
I don’t know
C9. Considering the walker you use
now, do you get your
accessories, parts, maintenance
and repairs from more than one
equipment supplier?
1 Yes
2 No
98 I don’t know
C10. Overall, how would you rate the
supplier that you use most?
1
2
3
4
5

Poor
Fair
Good
Very good
Excellent

C11. Would you recommend this
supplier to a friend who needed
similar equipment and
services?
1
2

Yes
No

Walker Survey

RECENT EXPERIENCES
Please answer the following questions
about the supplier that you use most
often if you use more than one supplier
for your walker and accessories.

D1.

During the past six months, how
reliable was your supplier in making
deliveries or repairs?

D3. In the past six months, have you
contacted your supplier to get
emergency service or advice
about your walker?
1 Yes
2 No (→Skip to D4)
98 I don’t know (→Skip to D4)

D3a. In general, how fast did the
supplier respond to your needs,
either by phone or in person?
Would you say…

1
2
3
99

Very reliable
Somewhat reliable
Not reliable at all
Does not apply

D2.

In the past six months, have you
contacted your supplier with a
complaint or a problem?

1
2
98
4

Yes
No (→Skip to D5)
I don’t know (→Skip to D5)
Don’t know how to contact my supplier
(→Skip to D5)

D2a.

When you contacted your supplier,
was your complaint or problem
settled to your satisfaction?

D4. In the past six months, have you
needed to contact your supplier
after regular business hours?

1
2
3
98

Yes
No
I am waiting for it to be settled
I don’t know

1 Yes
2 No (→Skip to D5)
98 I don’t know (→Skip to D5)

1
2
3
4
98

Within 1 day
Within 2 days
Within 1 week
Longer than 1 week
I don’t know

D3b. Were you able to get the
emergency service or advice
you needed?
1 Yes
2 No
98 I don’t know

Walker Survey

D4a.

1
2
98

D5.

1
2
98

When you contacted your supplier
after business hours, were you able
to get the service or advice you
needed?
Yes
No
I don’t know

In the past six months, have you
changed your walker supplier?
Yes
No (→Skip to SECTION E on page 11)
I don’t know (→Skip to SECTION E on
page 11)

D5a. Why did you change your
walker supplier? (Please check
all that apply.)
1
2
3
4
5
6
7
8
9
10
96

I moved
Supplier no longer accepted Medicare
Supplier went out of business
I was not happy with the quality of
service
I was not happy with equipment
I was not happy with the choices of
equipment or service I could get
I was not happy with the assistance I
got in handling the insurance
Supplier did not provide walker,
accessories or repair service I needed
I changed to an HMO and had to use a
different supplier
Supplier became ineligible to provide
the equipment under Medicare
Other, please specify:
_________________________

Walker Survey

ABOUT YOU
E5.

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

1
2

8th grade or less
Some high school but did not
graduate
High school graduate or GED
Some college or technical school
College graduate
More than a 4-year college degree

Section E is about you, the person
whose name is on the mailing label of
this survey.
E1.

In general, how would you rate your
overall health?

1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

E2.

Compared to 1 year ago, how would
you rate your health now? Would
you say …

1
2
3
4
5

Much better now
Somewhat better now
About the same
Somewhat worse now
Much worse now

E3.

Do you currently live alone?

1
2

Yes (→Skip to E5)
No

E4.

Which best describes your living
situation now? (Please check all that
apply.) I live…

1
2
3
4
5
6

With spouse/partner
With parent/step-parent
With child/children
With other relative(s)
With friend
With other person(s) not related to me

3
4
5
6

E6.

What was your household’s
annual income during 2006
before taxes?

1

Less than $5,000 ($416 per
month)
Between $5,001 and $10,000
($417–$833 per month)
Between $10,001 and $20,000
($834–$1,666 per month)
Between $20,001 and $30,000
($1,667–2,500 per month)
Between $30,001 and $50,000
($2,501–$4,167 per month)
Over $50,000 (over $4,168 per
month)

2
3
4
5
6

E7.

Are you of Hispanic or Latino
origin or descent?

1
2

Yes, Hispanic or Latino
No, not Hispanic or Latino

Walker Survey

E8.

How would you describe your race?
(Please check all that apply.)

American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or other Pacific
Islander
White or Caucasian
5
Other, please specify:
96
______________________
1
2
3
4

F. OTHER INFORMATION
F1.

Please check the correct
statement:

1

I am the person to whom this survey
was addressed (→ Skip to END)
I filled this survey out or helped fill
it out for someone else

2

F2.

How did you help the person
with this survey?

1

I wrote the answers that the
person told me
I answered the questions myself
based on my knowledge of the
person’s condition
Both of the above

2

3

END

Walker Survey

Thank you for completing the survey. Please return the completed survey in
the postage-paid envelope addressed to:

Survey of Medicare Patients
Abt Associates Inc.
55 Wheeler Street,
Cambridge, MA 02138

If you have any questions about the survey, please call toll-free 1-888738-6663.
If you have any questions about Medicare, please visit the website of the
Center for Medicare Services at: http://www.medicare.gov/, or call 1-800MEDICARE.

File Type	application/pdf
File Title	Abt Single-Sided Body Template
Author	Administrator
File Modified	2010-03-26
File Created	2010-03-26