Form #1 Form #1 CAHPS Cancer Care Questionnaires
Questionnaire and Data Collection Testing, Evaluation, and Research for the Agency for Healthcare Research and Quality
Attachment A - CAHPS Cancer Care Questionnaires 11-2-2011
Pretest of Proposed CAHPS for Cancer Care Questions and Methodology
OMB: 0935-0124
Attachment A
Data Collection Instruments
Form
Approved
OMB No. 0935-0124
Exp. Date 05/31/2014
CAHPS Cancer Care Survey
Language: English
|
File
name: Last updated: September 28, 2011 |
Public
reporting burden for this collection of information is estimated to
average 20
minutes per response, the estimated time required to complete
the survey. An agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless
it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing
this burden, to: AHRQ Reports Clearance Officer Attention: PRA,
Paperwork Reduction Project (0935-0124) AHRQ,
540 Gaither Road, Room # 5036, Rockville, MD 20850.
Survey Instructions
Answer each question by marking the box to the left of your answer.
You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:
Yes
No If No, go to #1 on page 3 (whatever page the survey really begins on)
1. Radiation therapy uses high-energy radiation like x-rays or radioactive implants to kill cancer cells and shrink tumors. Our records show that you received radiation therapy to treat your cancer from the [NAME OF CANCER CENTER] within the last 3 months.
Is that right?
Yes
No If No, please stop and return the survey in the enclosed envelope
2. How long have you been treated at [NAME OF CANCER CENTER] for cancer?
Less than 3 months ago
At least 3 months but less than 1 year
At least 1 year but less than 2 years
2 years or more
3. When were you first diagnosed with this cancer?
Less than 3 months ago
3 to 6 months ago
7 months to 11 months ago
1 year to 2 years ago
More than 2 years ago
Care after Diagnosis: Choosing and Understanding Cancer Treatment
4. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] tell you about different ways to treat your cancer?
Yes
No If No, go to #7
5. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] clearly explain the advantages and disadvantages of each choice for treatment?
Yes, definitely
Yes, somewhat
No
6. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] encourage you to give your opinion about each choice of cancer treatment?
Yes, definitely
Yes, somewhat
No
7. Since this cancer was diagnosed, did your doctor or other health professional at [NAME OF CANCER CENTER] involve you in decisions about your cancer treatment as much as you wanted?
Yes, definitely
Yes, somewhat
No
Understanding Radiation Therapy and Contacting the Team
As you answer the questions in this survey, think only about your experiences with your radiation therapy at [NAME OF CANCER CENTER].
8. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] discuss with you the reasons you might not want to have radiation therapy?
Yes, definitely
Yes, somewhat
No
9. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] discuss with you the reasons you might want to have radiation therapy?
Yes, definitely
Yes, somewhat
No
10. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] ask what your preference was with regard to whether or not to have radiation therapy?
Yes, definitely
Yes, somewhat
No
Radiation therapy team refers to the doctors, nurses, therapists, technicians, and their support staff involved with your radiation therapy through [NAME OF CANCER CENTER].
11. Since you learned you would have radiation therapy, did your radiation therapy team encourage you to contact them with questions between visits?
Yes, definitely
Yes, somewhat
No
12. Since learned you would have radiation therapy, did your radiation therapy team tell you to call them immediately if you have certain symptoms or side effects?
Yes, definitely
Yes, somewhat
No
13. Since you learned you would have radiation therapy, did your radiation therapy team give you clear instructions about how to contact them outside of regular office hours?
Yes
No
14. Since you learned you would have radiation therapy, did your radiation therapy team clearly explain how your cancer and radiation therapy could affect your normal daily activities?
Yes, definitely
Yes, somewhat
No
Getting Radiation Therapy
As you answer the questions in this survey, think only about the doctors, nurses, therapists, technicians, and their support staff who were involved with your radiation therapy through [NAME OF CANCER CENTER] during the last 3 months. Together, these persons are called your radiation therapy team in the following questions.
15. In the last 3 months, how many times did you visit the cancer center in person for an appointment with members of your radiation therapy team? Do not include telephone calls or emails.
1 to 3 times
4 to 6 times
7 to 12 times
13 to 20 times
21 to 28 times
29 to 35 times
36 or more times
16. In the last 3 months, how often were your cancer center visits scheduled at times that were convenient for you?
Never
Sometimes
Usually
Always
Your Radiation Therapy Team
17. In the last 3 months, how often did your radiation therapy team treat you with courtesy and respect?
Never
Sometimes
Usually
Always
18. In the last 3 months, how often did your radiation therapy team show respect for what you had to say?
Never
Sometimes
Usually
Always
19. In the last 3 months, how often did you feel your radiation therapy team really cared about you as a person?
Never
Sometimes
Usually
Always
20. In the last 3 months, how often did your radiation therapy team listen carefully to you?
Never
Sometimes
Usually
Always
21. In the last 3 months, how often was your radiation therapy team direct and straightforward when talking with you about your cancer and radiation therapy?
Never
Sometimes
Usually
Always
22. In the last 3 months, how often did your radiation therapy team spend enough time with you?
Never
Sometimes
Usually
Always
23. In the last 3 months, did your radiation therapy team tell you what the next steps in your care would be?
Yes, definitely
Yes, somewhat
No
24. In the last 3 months, did your radiation therapy team seem up-to-date about how to treat your type of cancer?
Yes, definitely
Yes, somewhat
No
25. In the last 3 months, did your radiation therapy team delay your cancer treatment or a decision about your radiation therapy because they were missing test results or reports from other health professionals?
Yes, definitely
Yes, somewhat
No
26. In the last 3 months, did you get conflicting information about your care from different members of your radiation therapy team?
Yes, definitely
Yes, somewhat
No
Tests and Treatment
27. In the last 3 months, did you have blood tests, x-rays, scans, or other procedures as part of your cancer treatment? Do not include radiation therapy.
Yes
No If No, go to #30
28. How often were the blood tests, x-rays, scans, or other procedures scheduled to be done as soon as you thought you needed? Do not include radiation therapy.
Never
Sometimes
Usually
Always
29. In the last 3 months, how often did you have to wait longer for your test results than you expected?
Never
Sometimes
Usually
Always
30. Radiation therapy team refers to the doctors, nurses, therapists, technicians, and their support staff involved with treating your cancer through [NAME OF CANCER CENTER]. In the last 3 months, how often did your radiation therapy team explain test results in a way that was easy to understand?
Never
Sometimes
Usually
Always
31. In the last 3 months, did your radiation therapy team prescribe medicine that you had not taken before?
Yes
No If No, go to #33
32. In the last 3 months, did your radiation therapy team explain what that medicine was for in a way that was easy to understand?
Yes, definitely
Yes, somewhat
No
33. In the last 3 months, did you and your radiation therapy team talk about pain related to your cancer or radiation therapy?
Yes
No
34. In the last 3 months, were you bothered by pain from your cancer or radiation therapy?
Yes
No If No, go to #36
35. In the last 3 months, did your radiation therapy team advise you or help you deal with this pain?
Yes, definitely
Yes, somewhat
No
36. In the last 3 months, did you and your radiation therapy team talk about any changes in your energy levels related to your cancer or radiation therapy?
Yes
No
37. In the last 3 months, were you bothered by changes in your energy level related to your cancer or radiation therapy?
Yes
No If No, go to #39
38. In the last 3 months, did your radiation therapy team advise you or help you deal with these changes in your energy levels?
Yes, definitely
Yes, somewhat
No
39. In the last 3 months, did you and your radiation therapy team talk about any emotional problems, such as anxiety or depression, related to your cancer or radiation therapy?
Yes
No
40. In the last 3 months, did you have any emotional problems, such as anxiety or depression, related to your cancer or radiation therapy?
Yes
No If No, go to #42
41. In the last 3 months, did your radiation therapy team advise you or help you deal with these emotional problems?
Yes, definitely
Yes, somewhat
No
42. In the last 3 months, did you and your radiation therapy team talk about additional services to manage your cancer care at home, such as home health care, special medical equipment, or special supplies?
Yes, definitely
Yes, somewhat
No
43. In the last 3 months, did you need additional services to manage your cancer care at home, such as home health care, special medical equipment, or special supplies?
Yes
No If No, go to #45
44. Did your radiation therapy team help arrange these additional services?
Yes
No
45. In the last 3 months, did you and your cancer surgery team talk about things you can do to maintain your health during cancer treatment such as what to eat and what exercises to do?
Yes, definitely
Yes, somewhat
No
Family and Caregivers
46. In the last 3 months, were any family members or close friends present during discussions with your radiation therapy team about your cancer or cancer care?
Yes
No If No, go to #48
47. In the last 3 months, did your radiation therapy team involve your family members or close friends in discussions as much as you wanted?
Yes, definitely
Yes, somewhat
No
Language Interpreter Services
48. An interpreter is a person who repeats what someone says in a language used by another person; for example Spanish, Russian, Chinese, and American Sign Language. In the last 3 months, did you want your radiation therapy team to provide an interpreter to help you speak with your radiation therapy team?
Yes
No If No, go to #50
49. In the last 3 months, how often did you get an interpreter to help you speak with your radiation therapy team when you wanted one?
Never
Sometimes
Usually
Always
Overall Rating
50. Using any number from 0 to 10, where 0 is the worst radiation therapy team possible and 10 is the best radiation therapy team possible, what number would you use to rate your radiation therapy team over the last 3 months?
0 Worst radiation therapy team possible
1
2
3
4
5
6
7
8
9
10 Best radiation therapy team possible
About You
51. Other than radiation therapy, have you ever had any of the following cancer treatments or services from [NAME OF CANCER CENTER]?
Yes No
Diagnosis of your cancer, which involves determining if you have cancer
Planning of your treatment by surgeons, radiologists, or medical oncologists working together to review your case.
Drug therapy, which uses medicine to treat cancer. Examples include chemotherapy, hormonal therapy, or immunotherapy.
Surgery to treat your cancer.
Waiting and monitoring to see if treatment for your cancer is needed.
52. How do you prefer to make decisions about your radiation therapy?
You prefer to mainly make the decisions
You prefer for you and your doctor to make the decisions together
You prefer for your doctor to mainly make the decisions
EMBEDDED STUDY ARM 1
53. Are you currently being treated by a health professional for diabetes or high blood sugar?
Yes
No
54. Are you currently being treated by a health professional for high blood pressure or hypertension?
Yes
No
55. Are you currently being treated by a health professional for any heart condition including a heart attack, angina, or congestive heart failure?
Yes
No
56. Are you currently being treated by a health professional for a chronic lung disease, asthma, COPD, emphysema, or chronic bronchitis? Do not include cancer.
Yes
No
57. Are you currently being treated by a health professional for arthritis or joint problems?
Yes
No
58. Are you currently being treated by a health professional for a depression or anxiety disorder?
Yes
No
59. Are you currently being treated by a health professional for another health condition other than your cancer that has lasted more than three months and that is not listed above?
Yes
No If No, go to #66
60. For what other conditions are you currently being treated?
__________________________________
[Go to #66]
EMBEDDED STUDY ARM 2
61. In the last 12 months, did you get health care 3 or more times for a condition or problem? Do not include cancer, pregnancy, or menopause.
Yes
No
If No, go to #63
62. Is this a condition or problem that has lasted for at least 3 months?
Yes
No
63. Do you now need or take medicine prescribed by a doctor? Do not include birth control or a medicine for cancer.
Yes
No If No, go
to #66
64. Is this medicine to treat a condition that has lasted for at least 3 months? Do not include cancer, pregnancy, or menopause.
Yes
No
[Go to Q#66]
EMBEDDED STUDY ARM 3
65. In the last 12 months, did you get health care 3 or more times for the same condition or problem? Do not include cancer, pregnancy, or menopause.
Yes
No
END OF STUDY ARMS, BACK TO REGULAR ITEMS
66. In general, how would you rate your overall mental or emotional health?
Excellent
Very good
Good
Fair
Poor
67. In general, how would you rate your overall physical health?
Excellent
Very good
Good
Fair
Poor
68. What kind of health insurance or health care coverage do you have? Include those that pay for only one type of service (nursing home care, accidents, or dental care). Exclude private plans that only provide extra cash while hospitalized.
Yes No
Private health insurance, such as Kaiser Permanente or Blue Cross Blue Shield
Medicare
MediGap
Medicaid
CHIP, the Children's Health Insurance Program, or SCHIP
Military health care, such as TRICARE, VA, or CHAMP-VA
Indian Health Service
State-sponsored health plan
Other government program
Single service plan, such as dental, vision, prescriptions
No coverage of any type
Other, please specify _____________
69. What is your age?
18 to 20
21 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
70. Are you male or female?
Male
Female
71. What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
72. Are you of Hispanic or Latino origin or descent?
Yes, Hispanic or Latino
No, Not Hispanic or Latino
73. What is your race? Please mark one or more.
White
Black or African-American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
74. Did someone help you complete this survey?
Yes
No Thank
you.
Please return the completed survey in the postage-paid
envelope.
75. How did that person help you? Mark all that apply.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
Please print:
Thank you.
Please return the completed survey in the postage-paid envelope.
Form
Approved
OMB No. 0935-0124
Exp. Date 05/31/2014
CAHPS Cancer Care Survey
Language: English
|
File
name: Last updated: September 28, 2011 |
Public
reporting burden for this collection of information is estimated to
average 20
minutes per response, the estimated time required to complete
the survey. An agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless
it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing
this burden, to: AHRQ Reports Clearance Officer Attention: PRA,
Paperwork Reduction Project (0935-0124) AHRQ,
540 Gaither Road, Room # 5036, Rockville, MD 20850.
Survey Instructions
Answer each question by marking the box to the left of your answer.
You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:
Yes
No If No, go to #1 on page 3 (whatever page the survey really begins on)
1. Drug therapy for cancer involves taking medicine to treat your cancer. Examples of drug therapy are chemotherapy, immunotherapy, and hormonal therapy. Do not include radiation therapy or surgery. Our records show that you received drug therapy to treat your cancer from the [NAME OF CANCER CENTER] within the last 3 months.
Is that right?
Yes
No If No, please stop and return the survey in the enclosed envelope
2. How long have you been treated at [NAME OF CANCER CENTER] for cancer?
Less than 3 months ago
At least 3 months but less than 1 year
At least 1 year but less than 2 years
2 years or more
3. When were you first diagnosed with this cancer?
Less than 3 months ago
3 to 6 months ago
7 months to 11 months ago
1 year to 2 years ago
More than 2 years ago
Care after Diagnosis: Choosing and Understanding Cancer Treatment
4. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] tell you about different ways to treat your cancer?
Yes
No If No, go to #7
5. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] clearly explain the advantages and disadvantages of each choice for treatment?
Yes, definitely
Yes, somewhat
No
6. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] encourage you to give your opinion about each choice of cancer treatment?
Yes, definitely
Yes, somewhat
No
7. Since this cancer was diagnosed, did your doctor or other health professional at [NAME OF CANCER CENTER] involve you in decisions about your cancer treatment as much as you wanted?
Yes, definitely
Yes, somewhat
No
Understanding Drug Therapy and Contacting the Team
As you answer the questions in this survey, think only about your experiences with your drug therapy at [NAME OF CANCER CENTER].
8. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] discuss with you the reasons you might not want to have drug therapy?
Yes, definitely
Yes, somewhat
No
9. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] discuss with you the reasons you might want to have drug therapy?
Yes, definitely
Yes, somewhat
No
10. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] ask what your preference was with regard to whether or not to have drug therapy?
Yes, definitely
Yes, somewhat
No
Drug therapy team refers to the doctors, nurses, therapists, technicians, and their support staff involved with your drug therapy through [NAME OF CANCER CENTER].
11. Since you learned you would have drug therapy, did your drug therapy team encourage you to contact them with questions between visits?
Yes, definitely
Yes, somewhat
No
12. Since learned you would have drug therapy, did your drug therapy team tell you to call them immediately if you have certain symptoms or side effects?
Yes, definitely
Yes, somewhat
No
13. Since you learned you would have drug therapy, did your drug therapy team give you clear instructions about how to contact them outside of regular office hours?
Yes
No
14. Since you learned you would have drug therapy, did your drug therapy team clearly explain how your cancer and drug therapy could affect your normal daily activities?
Yes, definitely
Yes, somewhat
No
Getting Drug Therapy
As you answer the questions in this survey, think only about the doctors, nurses, therapists, technicians, and their support staff who were involved with your drug therapy through [NAME OF CANCER CENTER] during the last 3 months. Together, these persons are called your drug therapy team in the following questions.
15. In the last 3 months, how many times did you visit the cancer center in person for an appointment with members of your drug therapy team? Do not include telephone calls or emails.
1 to 3 times
4 to 6 times
7 to 12 times
13 to 20 times
21 to 28 times
29 to 35 times
36 or more times
16. In the last 3 months, how often were your cancer center visits scheduled at times that were convenient for you?
Never
Sometimes
Usually
Always
Your Drug Therapy Team
17. In the last 3 months, how often did your drug therapy team treat you with courtesy and respect?
Never
Sometimes
Usually
Always
18. In the last 3 months, how often did your drug therapy team show respect for what you had to say?
Never
Sometimes
Usually
Always
19. In the last 3 months, how often did you feel your drug therapy team really cared about you as a person?
Never
Sometimes
Usually
Always
20. In the last 3 months, how often did your drug therapy team listen carefully to you?
Never
Sometimes
Usually
Always
21. In the last 3 months, how often was your drug therapy team direct and straightforward when talking with you about your cancer and drug therapy?
Never
Sometimes
Usually
Always
22. In the last 3 months, how often did your drug therapy team spend enough time with you?
Never
Sometimes
Usually
Always
23. In the last 3 months, did your drug therapy team tell you what the next steps in your care would be?
Yes, definitely
Yes, somewhat
No
24. In the last 3 months, did your drug therapy team seem up-to-date about how to treat your type of cancer?
Yes, definitely
Yes, somewhat
No
25. In the last 3 months, did your drug therapy team delay your cancer treatment or a decision about your drug therapy because they were missing test results or reports from other health professionals?
Yes, definitely
Yes, somewhat
No
26. In the last 3 months, did you get conflicting information about your care from different members of your drug therapy team?
Yes, definitely
Yes, somewhat
No
Tests and Treatment
27. In the last 3 months, did you have blood tests, x-rays, scans, or other procedures as part of your cancer treatment? Do not include drug therapy.
Yes
No If No, go to #30
28. How often were the blood tests, x-rays, scans, or other procedures scheduled to be done as soon as you thought you needed? Do not include drug therapy.
Never
Sometimes
Usually
Always
29. In the last 3 months, how often did you have to wait longer for your test results than you expected?
Never
Sometimes
Usually
Always
30. Drug therapy team refers to the doctors, nurses, therapists, technicians, and their support staff involved with treating your cancer through [NAME OF CANCER CENTER]. In the last 3 months, how often did your drug therapy team explain test results in a way that was easy to understand?
Never
Sometimes
Usually
Always
31. In the last 3 months, did your drug therapy team prescribe medicine that you had not taken before?
Yes
No If No, go to #33
32. In the last 3 months, did your drug therapy team explain what that medicine was for in a way that was easy to understand?
Yes, definitely
Yes, somewhat
No
33. In the last 3 months, did you and your drug therapy team talk about pain related to your cancer or drug therapy?
Yes
No
34. In the last 3 months, were you bothered by pain from your cancer or drug therapy?
Yes
No If No, go to #36
35. In the last 3 months, did your drug therapy team advise you or help you deal with this pain?
Yes, definitely
Yes, somewhat
No
36. In the last 3 months, did you and your drug therapy team talk about any changes in your energy levels related to your cancer or drug therapy?
Yes
No
37. In the last 3 months, were you bothered by changes in your energy level related to your cancer or drug therapy?
Yes
No If No, go to #39
38. In the last 3 months, did your drug therapy team advise you or help you deal with these changes in your energy levels?
Yes, definitely
Yes, somewhat
No
39. In the last 3 months, did you and your drug therapy team talk about any emotional problems, such as anxiety or depression, related to your cancer or drug therapy?
Yes
No
40. In the last 3 months, did you have any emotional problems, such as anxiety or depression, related to your cancer or drug therapy?
Yes
No If No, go to #42
41. In the last 3 months, did your drug therapy team advise you or help you deal with these emotional problems?
Yes, definitely
Yes, somewhat
No
42. In the last 3 months, did you and your drug therapy team talk about additional services to manage your cancer care at home, such as home health care, special medical equipment, or special supplies?
Yes, definitely
Yes, somewhat
No
43. In the last 3 months, did you need additional services to manage your cancer care at home, such as home health care, special medical equipment, or special supplies?
Yes
No If No, go to #45
44. Did your drug therapy team help arrange these additional services?
Yes
No
45. In the last 3 months, did you and your cancer surgery team talk about things you can do to maintain your health during cancer treatment such as what to eat and what exercises to do?
Yes, definitely
Yes, somewhat
No
Family and Caregivers
46. In the last 3 months, were any family members or close friends present during discussions with your drug therapy team about your cancer or cancer care?
Yes
No If No, go to #48
47. In the last 3 months, did your drug therapy team involve your family members or close friends in discussions as much as you wanted?
Yes, definitely
Yes, somewhat
No
Language Interpreter Services
48. An interpreter is a person who repeats what someone says in a language used by another person; for example Spanish, Russian, Chinese, and American Sign Language. In the last 3 months, did you want your drug therapy team to provide an interpreter to help you speak with your drug therapy team?
Yes
No If No, go to #50
49. In the last 3 months, how often did you get an interpreter to help you speak with your drug therapy team when you wanted one?
Never
Sometimes
Usually
Always
Overall Rating
50. Using any number from 0 to 10, where 0 is the worst drug therapy team possible and 10 is the best drug therapy team possible, what number would you use to rate your drug therapy team over the last 3 months?
0 Worst drug therapy team possible
1
2
3
4
5
6
7
8
9
10 Best drug therapy team possible
About You
51. Other than drug therapy, have you ever had any of the following cancer treatments or services from [NAME OF CANCER CENTER]?
Yes No
Diagnosis of your cancer, which involves determining if you have cancer
Planning of your treatment by surgeons, radiologists, or medical oncologists working together to review your case.
Surgery to treat your cancer.
Radiation therapy, which uses high-energy radiation like x-rays or radioactive implants to treat cancer and shrink tumors.
Waiting and monitoring to see if treatment for your cancer is needed.
52. How do you prefer to make decisions about your drug therapy?
You prefer to mainly make the decisions
You prefer for you and your doctor to make the decisions together
You prefer for your doctor to mainly make the decisions
EMBEDDED STUDY ARM 1
53. Are you currently being treated by a health professional for diabetes or high blood sugar?
Yes
No
54. Are you currently being treated by a health professional for high blood pressure or hypertension?
Yes
No
55. Are you currently being treated by a health professional for any heart condition including a heart attack, angina, or congestive heart failure?
Yes
No
56. Are you currently being treated by a health professional for a chronic lung disease, asthma, COPD, emphysema, or chronic bronchitis? Do not include cancer.
Yes
No
57. Are you currently being treated by a health professional for arthritis or joint problems?
Yes
No
58. Are you currently being treated by a health professional for a depression or anxiety disorder?
Yes
No
59. Are you currently being treated by a health professional for another health condition other than your cancer that has lasted more than three months and that is not listed above?
Yes
No If No, go to #66
60. For what other conditions are you currently being treated?
__________________________________
[Go to #66]
EMBEDDED STUDY ARM 2
61. In the last 12 months, did you get health care 3 or more times for a condition or problem? Do not include cancer, pregnancy, or menopause.
Yes
No
If No, go to #63
62. Is this a condition or problem that has lasted for at least 3 months?
Yes
No
63. Do you now need or take medicine prescribed by a doctor? Do not include birth control or a medicine for cancer.
Yes
No If No, go
to #66
64. Is this medicine to treat a condition that has lasted for at least 3 months? Do not include cancer, pregnancy, or menopause.
Yes
No
[Go to Q#66]
EMBEDDED STUDY ARM 3
65. In the last 12 months, did you get health care 3 or more times for the same condition or problem? Do not include cancer, pregnancy, or menopause.
Yes
No
END OF STUDY ARMS, BACK TO REGULAR ITEMS
66. In general, how would you rate your overall mental or emotional health?
Excellent
Very good
Good
Fair
Poor
67. In general, how would you rate your overall physical health?
Excellent
Very good
Good
Fair
Poor
68. What kind of health insurance or health care coverage do you have? Include those that pay for only one type of service (nursing home care, accidents, or dental care). Exclude private plans that only provide extra cash while hospitalized.
Yes No
Private health insurance, such as Kaiser Permanente or Blue Cross Blue Shield
Medicare
MediGap
Medicaid
CHIP, the Children's Health Insurance Program, or SCHIP
Military health care, such as TRICARE, VA, or CHAMP-VA
Indian Health Service
State-sponsored health plan
Other government program
Single service plan, such as dental, vision, prescriptions
No coverage of any type
Other, please specify _____________
69. What is your age?
18 to 20
21 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
70. Are you male or female?
Male
Female
71. What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
72. Are you of Hispanic or Latino origin or descent?
Yes, Hispanic or Latino
No, Not Hispanic or Latino
73. What is your race? Please mark one or more.
White
Black or African-American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
74. Did someone help you complete this survey?
Yes
No Thank
you.
Please return the completed survey in the postage-paid
envelope.
75. How did that person help you? Mark all that apply.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
Please print:
Thank you.
Please return the completed survey in the postage-paid envelope.
Form
Approved
OMB No. 0935-0124
Exp. Date 05/31/2014
CAHPS Cancer Care Survey
Language: English
|
File
name: Last updated: September 28, 2011 |
Public
reporting burden for this collection of information is estimated to
average 20
minutes per response, the estimated time required to complete
the survey. An agency may not conduct or sponsor, and a person
is not required to respond to, a collection of information unless
it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing
this burden, to: AHRQ Reports Clearance Officer Attention: PRA,
Paperwork Reduction Project (0935-0124) AHRQ,
540 Gaither Road, Room # 5036, Rockville, MD 20850.
Survey Instructions
Answer each question by marking the box to the left of your answer.
You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:
Yes
No If No, go to #1 on page 3 (whatever page the survey really begins on)
1. Our records show that you received surgery to treat your cancer from the [NAME OF CANCER CENTER] within the last 3 months.
Is that right?
Yes
No If No, please stop and return the survey in the enclosed envelope
2. How long have you been treated at [NAME OF CANCER CENTER] for cancer?
Less than 3 months ago
At least 3 months but less than 1 year
At least 1 year but less than 2 years
2 years or more
3. When were you first diagnosed with this cancer?
Less than 3 months ago
3 to 6 months ago
7 months to 11 months ago
1 year to 2 years ago
More than 2 years ago
Care after Diagnosis: Choosing and Understanding Cancer Treatment
4. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] tell you about different ways to treat your cancer?
Yes
No If No, go to #7
5. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] clearly explain the advantages and disadvantages of each choice for treatment?
Yes, definitely
Yes, somewhat
No
6. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] encourage you to give your opinion about each choice of cancer treatment?
Yes, definitely
Yes, somewhat
No
7. Since this cancer was diagnosed, did your doctor or other health professional at [NAME OF CANCER CENTER] involve you in decisions about your cancer treatment as much as you wanted?
Yes, definitely
Yes, somewhat
No
Understanding Cancer Surgery and Contacting the Team
As you answer the questions in this survey, think only about your experiences with your cancer surgery at [NAME OF CANCER CENTER].
8. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] discuss with you the reasons you might not want to have cancer surgery?
Yes, definitely
Yes, somewhat
No
9. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] discuss with you the reasons you might want to have cancer surgery?
Yes, definitely
Yes, somewhat
No
10. Since this cancer was diagnosed, did a doctor or other health care professional at [NAME OF CANCER CENTER] ask what your preference was with regard to whether or not to have cancer surgery?
Yes, definitely
Yes, somewhat
No
Cancer surgery team refers to the doctors, nurses, therapists, technicians, and their support staff involved with your cancer surgery through [NAME OF CANCER CENTER].
11. Since you learned you would have cancer surgery, did your cancer surgery team encourage you to contact them with questions between visits?
Yes, definitely
Yes, somewhat
No
12. Since learned you would have cancer surgery, did your cancer surgery team tell you to call them immediately if you have certain symptoms or side effects?
Yes, definitely
Yes, somewhat
No
13. Since you learned you would have cancer surgery, did your cancer surgery team give you clear instructions about how to contact them outside of regular office hours?
Yes
No
14. Since you learned you would have cancer surgery, did your cancer surgery team clearly explain how your cancer and cancer surgery could affect your normal daily activities?
Yes, definitely
Yes, somewhat
No
Getting Cancer Surgery
As you answer the questions in this survey, think only about the doctors, nurses, therapists, technicians, and their support staff who were involved with your cancer surgery through [NAME OF CANCER CENTER] during the last 3 months. Together, these persons are called your cancer surgery team in the following questions.
15. In the last 3 months, how many times did you visit the cancer center in person for an appointment with members of your cancer surgery team? Do not include telephone calls or emails.
1 to 3 times
4 to 6 times
7 to 12 times
13 to 20 times
21 to 28 times
29 to 35 times
36 or more times
16. In the last 3 months, how often were your cancer center visits scheduled at times that were convenient for you?
Never
Sometimes
Usually
Always
Your Cancer Surgery Team
17. In the last 3 months, how often did your cancer surgery team treat you with courtesy and respect?
Never
Sometimes
Usually
Always
18. In the last 3 months, how often did your cancer surgery team show respect for what you had to say?
Never
Sometimes
Usually
Always
19. In the last 3 months, how often did you feel your cancer surgery team really cared about you as a person?
Never
Sometimes
Usually
Always
20. In the last 3 months, how often did your cancer surgery team listen carefully to you?
Never
Sometimes
Usually
Always
21. In the last 3 months, how often was your cancer surgery team direct and straightforward when talking with you about your cancer and cancer surgery?
Never
Sometimes
Usually
Always
22. In the last 3 months, how often did your cancer surgery team spend enough time with you?
Never
Sometimes
Usually
Always
23. In the last 3 months, did your cancer surgery team tell you what the next steps in your care would be?
Yes, definitely
Yes, somewhat
No
24. In the last 3 months, did your cancer surgery team seem up-to-date about how to treat your type of cancer?
Yes, definitely
Yes, somewhat
No
25. In the last 3 months, did your cancer surgery team delay your cancer treatment or a decision about your cancer surgery because they were missing test results or reports from other health professionals?
Yes, definitely
Yes, somewhat
No
26. In the last 3 months, did you get conflicting information about your care from different members of your cancer surgery team?
Yes, definitely
Yes, somewhat
No
Tests and Treatment
27. In the last 3 months, did you have blood tests, x-rays, scans, or other procedures as part of your cancer treatment? Do not include cancer surgery.
Yes
No If No, go to #30
28. How often were the blood tests, x-rays, scans, or other procedures scheduled to be done as soon as you thought you needed? Do not include cancer surgery.
Never
Sometimes
Usually
Always
29. In the last 3 months, how often did you have to wait longer for your test results than you expected?
Never
Sometimes
Usually
Always
30. Cancer surgery team refers to the doctors, nurses, therapists, technicians, and their support staff involved with treating your cancer through [NAME OF CANCER CENTER]. In the last 3 months, how often did your cancer surgery team explain test results in a way that was easy to understand?
Never
Sometimes
Usually
Always
31. In the last 3 months, did your cancer surgery team prescribe medicine that you had not taken before?
Yes
No If No, go to #33
32. In the last 3 months, did your cancer surgery team explain what that medicine was for in a way that was easy to understand?
Yes, definitely
Yes, somewhat
No
33. In the last 3 months, did you and your cancer surgery team talk about pain related to your cancer or cancer surgery?
Yes
No
34. In the last 3 months, were you bothered by pain from your cancer or cancer surgery?
Yes
No If No, go to #36
35. In the last 3 months, did your cancer surgery team advise you or help you deal with this pain?
Yes, definitely
Yes, somewhat
No
36. In the last 3 months, did you and your cancer surgery team talk about any changes in your energy levels related to your cancer or cancer surgery?
Yes
No
37. In the last 3 months, were you bothered by changes in your energy level related to your cancer or cancer surgery?
Yes
No If No, go to #39
38. In the last 3 months, did your cancer surgery team advise you or help you deal with these changes in your energy levels?
Yes, definitely
Yes, somewhat
No
39. In the last 3 months, did you and your cancer surgery team talk about any emotional problems, such as anxiety or depression, related to your cancer or cancer surgery?
Yes
No
40. In the last 3 months, did you have any emotional problems, such as anxiety or depression, related to your cancer or cancer surgery?
Yes
No If No, go to #42
41. In the last 3 months, did your cancer surgery team advise you or help you deal with these emotional problems?
Yes, definitely
Yes, somewhat
No
42. In the last 3 months, did you and your cancer surgery team talk about additional services to manage your cancer care at home, such as home health care, special medical equipment, or special supplies?
Yes, definitely
Yes, somewhat
No
43. In the last 3 months, did you need additional services to manage your cancer care at home, such as home health care, special medical equipment, or special supplies?
Yes
No If No, go to #45
44. Did your cancer surgery team help arrange these additional services?
Yes
No
45. In the last 3 months, did you and your cancer surgery team talk about things you can do to maintain your health during cancer treatment such as what to eat and what exercises to do?
Yes, definitely
Yes, somewhat
No
Family and Caregivers
46. In the last 3 months, were any family members or close friends present during discussions with your cancer surgery team about your cancer or cancer care?
Yes
No If No, go to #48
47. In the last 3 months, did your cancer surgery team involve your family members or close friends in discussions as much as you wanted?
Yes, definitely
Yes, somewhat
No
Language Interpreter Services
48. An interpreter is a person who repeats what someone says in a language used by another person; for example Spanish, Russian, Chinese, and American Sign Language. In the last 3 months, did you want your cancer surgery team to provide an interpreter to help you speak with your cancer surgery team?
Yes
No If No, go to #50
49. In the last 3 months, how often did you get an interpreter to help you speak with your cancer surgery team when you wanted one?
Never
Sometimes
Usually
Always
Overall Rating
50. Using any number from 0 to 10, where 0 is the worst cancer surgery team possible and 10 is the best cancer surgery team possible, what number would you use to rate your cancer surgery team over the last 3 months?
0 Worst cancer surgery team possible
1
2
3
4
5
6
7
8
9
10 Best cancer surgery team possible
About You
51. Other than cancer surgery, have you ever had any of the following cancer treatments or services from [NAME OF CANCER CENTER]?
Yes No
Diagnosis of your cancer, which involves determining if you have cancer
Planning of your treatment by surgeons, radiologists, or medical oncologists working together to review your case.
Drug therapy, which uses medicine to treat cancer. Examples include chemotherapy, hormonal therapy, or immunotherapy.
Radiation therapy, which uses high-energy radiation like x-rays or radioactive implants to treat cancer and shrink tumors.
Waiting and monitoring to see if treatment for your cancer is needed.
52. How do you prefer to make decisions about your cancer surgery?
You prefer to mainly make the decisions
You prefer for you and your doctor to make the decisions together
You prefer for your doctor to mainly make the decisions
EMBEDDED STUDY ARM 1
53. Are you currently being treated by a health professional for diabetes or high blood sugar?
Yes
No
54. Are you currently being treated by a health professional for high blood pressure or hypertension?
Yes
No
55. Are you currently being treated by a health professional for any heart condition including a heart attack, angina, or congestive heart failure?
Yes
No
56. Are you currently being treated by a health professional for a chronic lung disease, asthma, COPD, emphysema, or chronic bronchitis? Do not include cancer.
Yes
No
57. Are you currently being treated by a health professional for arthritis or joint problems?
Yes
No
58. Are you currently being treated by a health professional for a depression or anxiety disorder?
Yes
No
59. Are you currently being treated by a health professional for another health condition other than your cancer that has lasted more than three months and that is not listed above?
Yes
No If No, go to #66
60. For what other conditions are you currently being treated?
__________________________________
[Go to #66]
EMBEDDED STUDY ARM 2
61. In the last 12 months, did you get health care 3 or more times for a condition or problem? Do not include cancer, pregnancy, or menopause.
Yes
No
If No, go to #63
62. Is this a condition or problem that has lasted for at least 3 months?
Yes
No
63. Do you now need or take medicine prescribed by a doctor? Do not include birth control or a medicine for cancer.
Yes
No If No, go
to #66
64. Is this medicine to treat a condition that has lasted for at least 3 months? Do not include cancer, pregnancy, or menopause.
Yes
No
[Go to Q#66]
EMBEDDED STUDY ARM 3
65. In the last 12 months, did you get health care 3 or more times for the same condition or problem? Do not include cancer, pregnancy, or menopause.
Yes
No
END OF STUDY ARMS, BACK TO REGULAR ITEMS
66. In general, how would you rate your overall mental or emotional health?
Excellent
Very good
Good
Fair
Poor
67. In general, how would you rate your overall physical health?
Excellent
Very good
Good
Fair
Poor
68. What kind of health insurance or health care coverage do you have? Include those that pay for only one type of service (nursing home care, accidents, or dental care). Exclude private plans that only provide extra cash while hospitalized.
Yes No
Private health insurance, such as Kaiser Permanente or Blue Cross Blue Shield
Medicare
MediGap
Medicaid
CHIP, the Children's Health Insurance Program, or SCHIP
Military health care, such as TRICARE, VA, or CHAMP-VA
Indian Health Service
State-sponsored health plan
Other government program
Single service plan, such as dental, vision, prescriptions
No coverage of any type
Other, please specify _____________
69. What is your age?
18 to 20
21 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
70. Are you male or female?
Male
Female
71. What is the highest grade or level of school that you have completed?
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
72. Are you of Hispanic or Latino origin or descent?
Yes, Hispanic or Latino
No, Not Hispanic or Latino
73. What is your race? Please mark one or more.
White
Black or African-American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native
74. Did someone help you complete this survey?
Yes
No Thank
you.
Please return the completed survey in the postage-paid
envelope.
75. How did that person help you? Mark all that apply.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way
Please print:
Thank you.
Please return the completed survey in the postage-paid envelope.
-
C
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | CAHPS Health Plan Survey 4.0: Adult Commercial Questionnaire |
| Subject | Survey of health plan enrollees' experiences with care |
| Author | AIR and Mayo |
| File Modified | 0000-00-00 |
| File Created | 2021-02-01 |
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