Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX
Attachment I.1: Patient Survey
Demonstration of Health Literacy Universal Precautions Toolkit
Date:
Instructions:
Please answer the questions below about the care provided by [name of practice/clinic]. Your answers will help us learn how well people in your providers’ office [clinic] explain things to you. We will not share your answers with anyone in your providers’ office [clinic].
First, we would like to know how well the providers and other staff in this office explain things to you and how well they listen to you.
In the last 6 months, how often did people in this office [clinic] explain things in a way that was easy to understand?
Never
Sometimes
Usually
Always
In the last 6 months, how often did anyone in this doctor’s office use pictures, drawings, models, or videos to explain things to you?
Never
Sometimes
Usually
Always
Public reporting burden for this collection of information is
estimated to average 20 minutes per response, the estimated
time required to participate in this 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. Form Approved: OMB Number 0935-XXXX Exp. Date
xx/xx/20xx. Send comments regarding this burden estimate or
any other aspect of this collection of information, including
suggestions for reducing this burden, to: AHRQ Reports Clearance
Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX)
AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.
In the last 6 months, how often did people in this office [clinic] talk too fast when talking with you?
Never
Sometimes
Usually
Always
In the last 6 months, how often did people in this office [clinic] use medical words that you did not understand?
Never
Sometimes
Usually
Always
In the last 6 months, how often did you feel that people in this office [clinic] wanted you to ask them questions?
Never
Sometimes
Usually
Always
In the last 6 months, how often did people in this office [clinic] show interest in your questions and concerns?
Never
Sometimes
Usually
Always
In the last 6 months, how often did people in this office [clinic] listen carefully to you?
Never
Sometimes
Usually
Always
In the last 6 months, how often did people in this office [clinic] spend enough time with you?
Never
Sometimes
Usually
Always
In the last 6 months, how often did people in this office [clinic] interrupt you when you were talking?
Never
Sometimes
Usually
Always
In the last 6 months, did you see anyone in this office [clinic] for a specific illness or for any health condition?
Yes
No go to question 14
In the last 6 months, did anyone in this office [clinic] give you verbal instructions about what to do to take care of this illness or health condition?
Yes
No go to question 14
In the last 6 months, how often were these verbal instructions easy to understand?
Never
Sometimes
Usually
Always
In the last 6 months, how often did anyone in this office [clinic] ask you to describe how you were going to follow these instructions?
Never
Sometimes
Usually
Always
Now we would like to know how well providers and other staff in this office [clinic] have done in talking with you about any medicines that you take.
In the last 6 months, did you take any medicine?
Yes
No go to question 22
In the last 6 months, did anyone from this office ask you to bring to this office [clinic] all the prescription and over-the-counter medicines you were taking?
Yes
No
In the last 6 months, did anyone in this office [clinic] look at your medicine bottles and talk with you about each medicine?
Yes
No
In the last 6 months, did anyone in this office [clinic] explain the purpose for taking these medicines?
Yes
No go to question 19
How often was the explanation easy to understand?
Never
Sometimes
Usually
Always
In the last 6 months, did anyone in this office [clinic] explain when to take these medicines?
Yes
No go to question 21
How often was the explanation easy to understand?
Never
Sometimes
Usually
Always
In the last 6 months, how often did anyone in this office [clinic] suggest ways to help you remember to take your medicines?
Never
Sometimes
Usually
Always
Now, we would like to know whether your provider or other staff in this office [clinic] have given you written information about your health.
In the last 6 months, did anyone in this office [clinic] give you written materials about how to take care of your health?
Yes
No go to question 24
In the last 6 months, how often did anyone in this office [clinic] explain or walk you through the written information that you were given?
Never
Sometimes
Usually
Always
In the last 6 months, did you have to sign any forms at this office [clinic]?
Yes
No go to question 26
In the last 6 months, how often did someone explain the purpose of a form before you signed it?
Never
Sometimes
Usually
Always
In the last 6 months, did you fill out any forms at this office [clinic]?
Yes
No go to question 29
In the last 6 months, how often were you offered help in filling out a form at this office [clinic]?
Never
Sometimes
Usually
Always
In the last 6 months, how often were the forms that you got at this office [clinic] easy to fill out?
Never
Sometimes
Usually
Always
Now, we want to know whether your provider and other staff in this office [clinic] have talked with you about classes or other services in the community that might be helpful for you.
In the last 6 months, how often did anyone in this office [clinic] suggest that you go to a support group or class to help you take care of your health?
Never
Sometimes
Usually
Always
In the last 6 months, did you and anyone in this office [clinic] talk about what was available in your community to help you manage your health?
Yes
No
In the last 6 months, did anyone in this office [clinic] ask if you want to improve your reading, writing, or math skills?
Yes
No
In the last 6 months, did anyone in this doctor’s office [clinic] help you get services to improve your reading, writing, or math skills?
Yes
No
Now, we have some questions about you and your health.
In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
What is your age?
18 to 24
25 to 34
35
to 44
45 to 54
55 to 64
65 to 74
75 or older
Are you male or female?
Male
Female
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
Are you of Hispanic or Latino origin or descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino
What is your race? (Please mark all that apply)
White
Black or African
American
Asian
Native
Hawaiian or Other Pacific Islander
American Indian or Alaskan Native
Other
How well do you speak English?
Very well
Well
Not
well
Not at all
How confident are you filling out medical forms by yourself?
Extremely
Quite a bit
Somewhat
A
little bit
Not at all
Finally, we would like to know your opinion of the provider you saw today and to find out if anyone helped you answer these questions.
Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?
0 (Worst provider possible)
1
2
3
4
5
6
7
8
9
10
(Best provider possible)
Did someone help you complete this survey?
Yes
No You are finished filling out this survey. Thank you.
How did that person help you? (Please 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 specify: _______________________________________)
Thank you for taking the time to complete this survey!
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Demonstration of Health Literacy Universal Precautions Toolkit
|
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Liz Horsley |
| File Modified | 0000-00-00 |
| File Created | 2021-01-30 |