S5

Development and Year One National Implementation of the
CAHPS Survey for the Medicare Shared Savings Program
and Pioneer Model ACOs

Clare Stevens, Rebecca Anhang Price, Julie A. Brown, Robin M. Weinick

RAND Health

November 20, 2013
Prepared for the Centers for Medicare & Medicaid Services

Project Overview
This report provides an overview of the Centers for Medicare & Medicaid Services (CMS) effort to
develop and implement a survey about patient experience based on the CAHPS® Clinician & Group
Survey (CG-CAHPS). CMS is using this survey to collect data on fee-for-service Medicare beneficiaries’
experiences in Accountable Care Organizations (ACOs) that participate in the Medicare Shared Savings
Program and Pioneer Model. Scores from this survey will comprise one-quarter of each ACO’s total
quality score, which is used to determine the ACO’s shared savings payment. Survey development and
implementation will also inform the future use of surveys about patient experience for group practices
that participate in the Physician Quality Reporting System (PQRS).

Survey Development Overview
On November 2, 2011, the Centers for Medicare & Medicaid Services (CMS) finalized rules under the
Affordable Care Act establishing the Shared Savings Program. As a part of this program, doctors, hospitals,
and other health care providers may work together to better coordinate care for Medicare patients through
an ACO.1 CMS will measure the quality of care provided by ACOs using 33 nationally recognized
measures in 4 key domains:
• Patent/caregiver experience
• Care coordination/patient safety
• Preventative health
• At risk population
The rule required that the patient experience survey for the program be based on the CG-CAHPS survey.
Here, we briefly summarize the survey development process and provide information on both the field test
and the Year 1 National Implementation Survey.

Federal Rule and CG-CAHPS Required Domains
The first draft of the ACO patient experience survey had seven summary survey measures that were
specified for inclusion by CMS’ Federal Rule for the Shared Savings Program:
1. Getting Timely Care, Appointments, and Information
2. How Well Your Providers Communicate
3. Patients’ Rating of Provider
4. Access to Specialists
5. Health Promotion and Education
6. Shared Decision Making
7. Health Status/Functional Status

1

 The Medicare Shared Savings Program final rule is available at:

http://www.cms.gov/SharedSavingsProgram/30_Statutes_Regulations_Guidance.asp#TopOfPageThe
  2

The first 6 of these summary survey measures come from CG-CAHPS question sets.1 The health
status/functional status summary survey measure includes questions required by Section 4302 of the
Affordable Care Act relating to disability status 2 and additional questions regarding health and functional
status, including questions modified from the SF-36, a widely used and well-validated health outcomes
survey. The first draft of the survey also included the CG-CAHPS summary survey measure “Courteous
and Helpful Office Staff,” as this measure is part of the CG-CAHPS core questions set and is required for
all CG-CAHPS surveys.

Development of the Field Test Survey
To identify additional aspects of care for which it might be helpful to collect beneficiary experience
data, we conducted two focus groups with Medicare beneficiaries. We also convened a Technical Expert
Panel (TEP) including representatives of groups that accredit health care organizations, health care
purchasers and consumers, health care organizations and providers, as well as experts on survey research
and performance measurement and improvement. As a result, we adapted CG-CAHPS questions in the
Health Promotion and Education and Care Coordination summary survey measures by using the term
“health care team” in questions referring to the set of health care providers responsible for an individual’s
care, and by developing new survey questions regarding the involvement of friends and family in health
care decision-making. We also included questions about four additional aspects of patient experience:
Care Coordination; Between Visit Communication; Helping You to Take Medications as Directed; and
Stewardship of Patient Resources. Questions comprising these summary survey measures were adapted
from CAHPS supplemental question sets.
To inform the order of survey topics and ensure consistent interpretation of survey questions by
beneficiaries, we used the draft survey to conduct cognitive interviews with fee-for-service Medicare
beneficiaries. We revised the survey based on the results of these interviews.
The field test survey had 96 questions organized into the following sections: Your Provider (3
questions), Your Care From This Provider in the Last 6 Months (40 questions), Clerks and Receptionists
at This Provider’s Office (2 questions), Your Care from Specialists in the Last 6 Months (5 questions),
All Your Care in the Last 6 Months (16 questions), and About You (30 questions). The survey asked
about beneficiaries’ experiences with their care in the previous 6 months. The survey referenced, by
name, the provider who delivered the plurality of the beneficiary’s primary care in the prior 12 months.

1

CG-CAHPS Core measures are questions which survey sponsors are required to field in order to refer to
their survey as a CG-CAHPS survey. CAHPS supplemental questions explore topics or domains that are
not covered by core measures, or explore core measures in richer detail.
2
The Department of Health and Human Services Office of Minority Health (OMH) Final Data Collection
Standard relating to Section 4302 of the Affordable Care Act is available at:
http://minorityhealth.hhs.gov/templates/content.aspx?ID=9227&lvl=2&lvlID=208
3

Field Test Implementation and Data Analysis
Between April 27 and June 29, 2012, we field-tested the draft survey among beneficiaries assigned to
9 participating physician groups from the Medicare Physician Group Practice Transition Demonstration
(PGPs). The field test included an oversample of beneficiaries who ranked within the top 10 percent of
each ACO by their total value of allowed primary care charges. The data collection included mailing of
a pre-notification letter, up to two mailings of paper surveys, and telephone interviews with those sampled
beneficiaries who did not respond to the mail survey. The mail survey and telephone interviews were
available in English and Spanish. There were 3,445 responses to the field test survey, and the adjusted
response rate after excluding those ineligible for the survey was 53 percent.
After the field test, we conducted data analysis to combine answers to related questions to form
summary survey measures. Based on the results of these analyses and the removal of questions that had
been included more than once to assess question order effects, the survey content was shortened to 83
questions.

Year 1 National Implementation Survey
The first national implementation of the CAHPS Survey for the Medicare Shared Savings Program
and Pioneer Model ACOs was fielded among beneficiaries assigned to 146 ACOs and 6 PGPs; they are
described as ACOs throughout the remainder of this report. The survey was administered between
January and April 2013 and measured beneficiaries’ experiences of care over the previous six months.
The survey contained the 83 questions kept after the analysis of the field test data, organized into the
following sections: Your Provider (3 questions), Your Care From This Provider in the Last 6 Months (38
questions), Clerks and Receptionists at This Provider’s Office (2 questions), Your Care from Specialists
in the Last 6 Months (5 questions), All Your Care in the Last 6 Months (10 questions), and About You
(25 questions). Many of the evaluative questions included in the survey are preceded by screener
questions, so that only those beneficiaries for whom the question is relevant (i.e., those with applicable
needs or experiences) are asked to answer the evaluative questions. The 12 summary survey measures
come from these evaluative questions. Table 1 below describes the questions that comprise each of the 12
summary survey measures.

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Table 1. Year 1 National Implementation of the CAHPS Survey for the Medicare Shared Savings Program
and Pioneer Model ACOs – Summary Survey Measures and Questions
Measure
Used to
Summary
Determine
Question(s) Included in the Measure
Survey Measure
ACO’s
Quality
Score?
In the last 6 months, when you phoned this provider’s office
to get an appointment for care you needed right away, how
often did you get an appointment as soon as you needed?
In the last 6 months, when you made an appointment for a
check-up or routine care with this provider, how often did
you get an appointment as soon as you needed?
Getting Timely
Care,
Appointments
and Information

In the last 6 months, when you phoned this provider’s office
during regular office hours, how often did you get an answer
to your medical question that same day?

Yes

In the last 6 months, when you phoned this provider’s office
after regular office hours, how often did you get an answer
to your medical question as soon as you needed?
Wait time includes time spent in the waiting room and exam
room. In the last 6 months, how often did you see this
provider within 15 minutes of your appointment time?
In the last 6 months, how often did this provider explain
things in a way that was easy to understand?
In the last 6 months, how often did this provider listen
carefully to you?

How Well
Providers
Communicate

In the last 6 months, how often did this provider give you
easy to understand information about these health questions
or concerns?

Yes

In the last 6 months, how often did this provider seem to
know the important information about your medical history?
In the last 6 months, how often did this provider show
respect for what you had to say?
In the last 6 months, how often did this provider spend
enough time with you?
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Patient’s Rating
of Provider

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?

Yes

In the last 6 months, how often was it easy to get
appointments with specialists?
Access to
Specialists

In the last 6 months, how often did the specialist you saw
most seem to know the important information about your
medical history?

Yes

General Health Promotion and Education
In the last 6 months, did you and anyone on your health care
team talk about specific things you could do to prevent
illness?
In the last 6 months, did you and anyone on your health care
team talk about a healthy diet and healthy eating habits?
Health
Promotion and
Education

Yes

In the last 6 months, did you and anyone on your health care
team talk about the exercise or physical activity you get?
In the last 6 months, did anyone on your health care team
talk with you about specific goals for your health?
Mental Health Promotion and Education
In the last 6 months, did anyone on your health care team ask
you if there was a period of time when you felt sad, empty,
or depressed?

Yes

In the last 6 months, did you and anyone on your health care
team talk about things in your life that worry you or cause
you stress?
Making Decisions about Medications
Did you and this provider talk about the reasons you might
want to take a medicine?
Shared DecisionMaking

Did you and this provider talk about the reasons you might
not want to take a medicine?

Yes

When you and this provider talked about starting or stopping
a prescription medicine, did this provider ask what you
thought was best for you?

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Making Decisions about Surgery
Did you and this provider talk about the reasons you might
want to have the surgery or procedure?
Did you and this provider talk about the reasons you might
not want to have the surgery or procedure?

Yes

When you and this provider talked about having surgery or a
procedure, did this provider ask what you thought was best
for you?
Sharing Your Health Information
In the last 6 months, did you and this provider talk about
how much of your personal health information you wanted
shared with your family or friends?

Yes

In the last 6 months, did this provider respect your wishes
about how much of your personal health information to share
with your family or friends?

Health Status/
Functional
Status*

Self-Rated Health
In general, how would you rate your overall health?

Yes

Self-Rated Mental Health
In general, how would you rate your overall mental or
emotional health?

Yes

Cognitive Functioning
Because of a physical, mental, or emotional condition, do
you have serious difficulty concentrating, remembering, or
making decisions?

Yes

Beneficiaries without a Chronic Condition
In the past 12 months, have you seen a provider 3 or more
times for condition or problem that has lasted for at least 3
months?

Yes

Do you need or take medicine to treat the condition?

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Beneficiaries’ Functional Status
During the last 4 weeks, how much did your physical health
interfere with your normal social activities with family,
friends, neighbors or groups?
During the last 4 weeks, how much of the time did your
physical health interfere with your social activities (like
visiting with friends, relatives, etc.)?

Yes

Do you have serious difficulty walking or climbing stairs?
Do you have difficulty dressing or bathing?
Because of a physical, mental, or emotional condition, do
you have difficulty doing errands alone such as visiting a
doctor’s office or shopping?
Courteous and
Helpful Office
Staff

In the last 6 months, how often were clerks and receptionists
at this provider’s office as helpful as you thought they
should be?

No

In the last 6 months, how often did clerks and receptionists
at this provider’s office treat you with courtesy and respect?
When you visited this provider in the last 6 months, how
often did he or she have your medical records?

Care
Coordination

In the last 6 months, when this provider ordered a blood test,
x-ray, or other test for you, how often did someone from this
provider’s office follow up to give you those results?

No

In the last 6 months, how often did you and anyone on your
health care team talk about all the prescription medicines
you were taking?
Between Visit
Communication

Helping You
Take
Medications as
Directed

In the last 6 months, did this provider’s office contact you to
remind you to make an appointment for tests or treatment?

No

In the last 6 months, how often did this provider give you
easy to understand instructions about how to take your
medicines?
Was the written information this provider gave you easy to
understand?

No

In the last 6 months, did this provider suggest ways to help
you remember to take your medicines?
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Stewardship of
In the last 6 months, did you and anyone on your health care
Patient
No
team talk about how much your prescription medicines cost?
Resources
* While questions included in the Health Status/Functional Status summary survey measure comprise one of
the seven summary survey measures included in federal regulation, they are currently treated as pay-forreporting.

Year 1 National Implementation Methodology
Sample Selection and Eligibility Criteria. We selected a sample of 117,800 beneficiaries (775
per ACO) who were assigned to one of the ACOs using the two-step assignment process.2 For each
ACO/PGP, the random sample of 775 beneficiaries included 194 beneficiaries drawn from the top 10
percent of users and 581 drawn from the remaining 90 percent of users. The top 10 percent of users in
each ACO was defined as those beneficiaries who ranked within the top 10 percent by their total
allowed primary care charges. The top 10% of utilizers were oversampled (1) to increase the
likelihood that the survey questions that measure less common experiences would receive adequate
numbers of responses; and (2) because one of the goals of the Medicare Shared Savings Program and
the Pioneer Model ACOs is to incentivize high quality and efficient service delivery, making it
particularly useful to capture the patient experiences of those with high levels of health care
utilization.
Survey Implementation. The survey was conducted between January 31 and April 15, 2013, and
asked about beneficiaries’ experiences with care received in the previous 6 months. The survey
referenced, by name, the provider who delivered the plurality of the beneficiary’s primary care visits
in the prior 12 months. The data collection protocol included mailing of a pre-notification letter, up to
two mailings of paper surveys, and telephone interviews with beneficiaries who did not respond to the
mail survey. The mail survey and telephone interviews were available in seven languages: English,
Spanish, Cantonese, Korean, Mandarin, Russian, and Vietnamese.
The sample disposition and response rates for the survey are presented in Table 2. Of the 117,800
beneficiaries in the sample, 208 (0.18%) were classified as ineligible because they were institutionalized,
deceased, had a language barrier that prevented them from participating in the survey, or were mentally
or physically incapable of responding. The adjusted response rate, after excluding all dispositions under
the ineligible category in Table 2 was 53.9 percent.

2

For information on the assignment methodology, please see http://www.cms.gov/Medicare/Medicare-Feefor-Service-Payment/sharedsavingsprogram/downloads/MSSP_FAQs.pdf.
9

Table 2. Sample Disposition, Year 1 National Implementation of the CAHPS Survey for the Medicare
Shared Savings Program and Pioneer Model ACOs
Disposition
Overall Sample Beneficiary
Overall Percentage of
Count
Sample
Completed survey
62,483
53.09 %
Partially completed survey
932
0.79 %
Ineligible
208
0.18 %
Institutionalized
7
0.01 %
Deceased
155
0.13%
Language Barrier
3
0.00%
Mentally or physically unable to respond
39
0.03 %
Other excluded from survey
4
0.00 %
Non-respondents
54,177
46.03 %
Total sample
117,700
100%

Data Analysis
Reliability of Scores. Reliability of the summary survey measures was also assessed and will
potentially inform decisions regarding calculation of an ACO's quality points in the future. Reliability
provides a statistical measure of the extent to which variation in the summary survey measures reflects
true differences between ACOs.
Case-Mix Adjustment. To ensure that comparisons among ACOs reflect differences in performance
rather than differences in case-mix, we adjusted for certain Medicare beneficiary characteristics. The
variables used in the final case-mix adjustment model for the Year 1 National Implementation Survey
were: age, education, self-rated health, self-rated mental health, Medicaid eligibility, eligibility for
Medicare’s low-income premium subsidy; receipt of assistance in completing the survey, and completion
of an Asian language (Cantonese, Korean, Mandarin, or Vietnamese) survey.
Additional Analyses and Finalizing the Year 2 National Implementation Survey. The Year 1
National Implementation Survey data were further analyzed to assess the potential existence of duplicative
questions and to assess how each question contributes to an ACO’s final score. Based on the results of
these analyses, three questions were dropped from the survey. Three new questions regarding receipt of
the flu shot were added, as this comprises an important measure of preventative care that can be difficult
to capture accurately in claims data; this concept is captured in other CMS CAHPS surveys as well. The
content for the Year 2 National Implementation Survey will therefore have 81 numbered questions,
including one 3-part question regarding receipt of the influenza vaccine; the survey is displayed in the
Appendix.

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Appendix. Contents of the Year 2 CAHPS Survey for the Medicare Shared Savings
Program and Pioneer Model ACOs
Your Provider
1.

Our records show that you visited the provider named below in the last 6 months.
Name of provider label goes here

Is that correct?
Yes
No (If No, go to #44 on page 9)
The questions in this survey will refer to the provider named in Question 1 as “this provider.”
Please think of that person as you answer the survey.
2.

Is this the provider you usually see if you need a check-up, want advice about a health problem, or get
sick or hurt?
Yes
No

3.

How long have you been going to this provider?
Less than 6 months
At least 6 months but less than 1 year
At least 1 year but less than 3 years
At least 3 years but less than 5 years
5 years or more

Your Care From This Provider in the Last 6 months
These questions ask about your own health care. Do not include care you got when you stayed overnight
in a hospital. Do not include the times you went for dental care visits.
4.

In the last 6 months, how many times did you visit this provider to get care for yourself?
None (If None, go to #44 on page 9)
1 time
2
3
4
5 to 9
10 or more times

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5. In the last 6 months, did you phone this provider’s office to get an appointment for an illness, injury or
condition that needed care right away?
Yes
No (If No, go to #7)
6.

In the last 6 months, when you phoned this provider’s office to get an appointment for care you
needed right away, how often did you get an appointment as soon as you needed?
Never
Sometimes
Usually
Always

7. In the last 6 months, did you make any appointments for a check-up or routine care with this
provider?
Yes
No (If No, go to #9)
8.

In the last 6 months, when you made an appointment for a check-up or routine care with this
provider, how often did you get an appointment as soon as you needed?
Never
Sometimes
Usually
Always

9.

In the last 6 months, did you phone this provider’s office with a medical question during regular office
hours?
Yes
No (If No, go to #11)

10. In the last 6 months, when you phoned this provider’s office during regular office hours, how often
did you get an answer to your medical question that same day?
Never
Sometimes
Usually
Always
11. In the last 6 months, did you phone this provider’s office with a medical question after regular office
hours?
Yes
No (If No, go to #13)

12

12. In the last 6 months, when you phoned this provider’s office after regular office hours, how often did
you get an answer to your medical question as soon as you needed?
Never
Sometimes
Usually
Always
13. Some offices remind patients about tests, treatment, or appointments in between their visits. In the last
6 months, did you get any reminders from this provider’s office between visits?
Yes
No (If No, go to #15)
14. In the last 6 months, did this provider’s office contact you to remind you to make an appointment
for tests or treatment?
Yes
No
15. Wait time includes time spent in the waiting room and exam room. In the last 6 months, how often did
you see this provider within 15 minutes of your appointment time?
Never
Sometimes
Usually
Always
16. In the last 6 months, how often did this provider explain things in a way that was easy to
understand?
Never
Sometimes
Usually
Always
17. In the last 6 months, how often did this provider listen carefully to you?
Never
Sometimes
Usually
Always
18. In the last 6 months, did you talk with this provider about any health questions or concerns?
Yes
No (If No, go to #20)

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19. In the last 6 months, how often did this provider give you easy to understand information about
these health questions or concerns?
Never
Sometimes
Usually
Always
20. In the last 6 months, how often did this provider seem to know the important information about
your medical history?
Never
Sometimes
Usually
Always
21. When you visited this provider in the last 6 months, how often did he or she have your medical
records?
Never
Sometimes
Usually
Always
22. In the last 6 months, how often did this provider show respect for what you had to say?
Never
Sometimes
Usually
Always
23. In the last 6 months, how often did this provider spend enough time with you?
Never
Sometimes
Usually
Always
24. In the last 6 months, did this provider order a blood test, x-ray, or other test for you?
Yes
No (If No, go to #26)

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25. In the last 6 months, when this provider ordered a blood test, x-ray, or other test for you, how often did
someone from this provider’s office follow up to give you those results?
Never
Sometimes
Usually
Always
26. In the last 6 months, did you and this provider talk about starting or stopping a prescription medicine?
Yes
No (If No, go to #35)
27. Did you and this provider talk about the reasons you might want to take a medicine?
Yes
No
28. Did you and this provider talk about the reasons you might not want to take a medicine?
Yes
No
29. When you and this provider talked about starting or stopping a prescription medicine, did this
provider ask what you thought was best for you?
Yes
No
30. After you and this provider talked about starting or stopping a prescription medicine, did you
start a prescription medicine?
Yes
No (If No, go to #35)
31. In the last 6 months, how often did this provider give you easy to understand instructions about how
to take your medicines?
Never
Sometimes
Usually
Always

32. In the last 6 months, other than a prescription, did this provider give you written information or write

15

down information about how to take your medicines?
Yes
No (If No, go to #34)
33. Was the written information this provider gave you easy to understand?
Yes
No
34. In the last 6 months, did this provider suggest ways to help you remember to take your medicines?
Yes
No
35. In the last 6 months, did you and this provider talk about having surgery or any type of procedure?
Yes
No (If No, go to #39)
36. Did you and this provider talk about the reasons you might want to have the surgery or procedure?
Yes
No
37. Did you and this provider talk about the reasons you might not want to have the surgery or
procedure?
Yes
No
38. When you and this provider talked about having surgery or a procedure, did this provider ask what
you thought was best for you?
Yes
No
39. In the last 6 months, did you and this provider talk about how much of your personal health
information you wanted shared with your family or friends?
Yes
No

40. In the last 6 months, did this provider respect your wishes about how much of your personal health

16

information to share with your family or friends?
Yes
No
41. 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?
Worst provider possible
1
2
3
4
5
6
7
8
9
10
Best provider possible

Clerks and Receptionists at This Provider’s Office
42. In the last 6 months, how often were clerks and receptionists at this provider’s office as helpful as you
thought they should be?
Never
Sometimes
Usually
Always
43. In the last 6 months, how often did clerks and receptionists at this provider’s office treat you with
courtesy and respect?
Never
Sometimes
Usually
Always

Your Care From Specialists in the Last 6 months

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44. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors
who specialize in one area of health care. Is the provider named in Question 1 of this survey a
specialist?
Yes (If Yes, go to #48)
No
45. In the last 6 months, did you try to make any appointments with specialists?
Yes
No (If No, go to #48)
46. In the last 6 months, how often was it easy to get appointments with specialists?
Never
Sometimes
Usually
Always
47. In the last 6 months, how often did the specialist you saw most seem to know the important
information about your medical history?
Never
Sometimes
Usually
Always

All Your Care in the Last 6 Months
These questions ask about all your health care. Include all the providers you saw for health care in the
last 6 months. Do not include the times you went for dental care visits.
48. Your health care team includes all the doctors, nurses and other people you see for health care. In the
last 6 months, did you and anyone on your health care team talk about specific things you could do
to prevent illness?
Yes
No
49. In the last 6 months, did you and anyone on your health care team talk about a healthy diet and
healthy eating habits?

18

Yes
No
50. In the last 6 months, did you and anyone on your health care team talk about the exercise or physical
activity you get?
Yes
No
51. In the last 6 months, did anyone on your health care team talk with you about specific goals for your
health?
Yes
No
52. In the last 6 months, did you take any prescription medicine?
Yes
No (If No, go to #550)
53. In the last 6 months, how often did you and anyone on your health care team talk about all the
prescription medicines you were taking?
Never
Sometimes
Usually
Always
54. In the last 6 months, did you and anyone on your health care team talk about how much your
prescription medicines cost?
Yes
No
55. In the last 6 months, did anyone on your health care team ask you if there was a period of time
when you felt sad, empty, or depressed?
Yes
No
56. In the last 6 months, did you and anyone on your health care team talk about things in your
life that worry you or cause you stress?
Yes
No
57. Since August 1, 2013, did anyone on your health care team…

19

a. Remind you to get a flu shot?
Yes
No
b. Ask if you got a flu shot somewhere else?
Yes
No
c. Give you a flu shot?
Yes
No

About You
58. In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
59. In general, how would you rate your overall mental or emotional health?
Excellent
Very good
Good
Fair
Poor
60. In the last 12 months, have you seen a doctor or other health provider 3 or more times for the same
condition or problem?
Yes
No (If No, go to #62)
61. Is this a condition or problem that has lasted for at least 3 months?
Yes
No
62. Do you now need or take medicine prescribed by a doctor?

20

Yes
No  If No, go to #64
63. Is this medicine to treat a condition that has lasted for at least 3 months?
Yes
No
64. During the last 4 weeks, how much of the time did your physical health interfere with your social
activities (like visiting with friends, relatives, etc.)?
All of the time
Most of the time
Some of the time
A little of the time
None of the time
65. What is your age?
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 69
70 to 74
75 to 79
80 to 84
85 or older
66. Are you male or female?
Male
Female
67. 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
68. How well do you speak English?
Very well

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Well
Not well
Not at all
69. Do you speak a language other than English at home?
Yes
No (If No, go to #71)
70. What is the language you speak at home?
Spanish
Chinese
Korean
Russian
Vietnamese
Some other language
ê Please print:________________
71. Are you deaf or do you have serious difficulty hearing?
Yes
No
72. Are you blind or do you have serious difficulty seeing, even when wearing glasses?
Yes
No
73. Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating,
remembering, or making decisions?
Yes
No
74. Do you have serious difficulty walking or climbing stairs?
Yes
No
75. Do you have difficulty dressing or bathing?
Yes
No
76. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such

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as visiting a doctor’s office or shopping?
Yes
No
77. Are you of Hispanic, Latino, or Spanish origin?
Yes, Hispanic, Latino, or Spanish
No, not Hispanic, Latino, or Spanish (If No, go to #79)
78. Which group best describes you?
Mexican, Mexican American, Chicano (Go to #79)
Puerto Rican (Go to #79)
Cuban (Go to #79)
Another Hispanic, Latino, or Spanish origin (Go to #79)
79. What is your race? Mark one or more.
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander

80. Did someone help you complete this survey?
Yes
No (If no, you have completed the survey, thank you.)
Please return the completed survey in the postage-paid envelope.
81. How did that person help you? Mark one or more.
Read the questions to me
Wrote down the answers I gave

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Answered the questions for me
Translated the questions into my language
Helped in some other way
ê Please print:______________________________

--END OF SURVEY, THANK YOU FOR YOUR TIME--

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