Form 0 Consumer Assessment of Healthcare Providers and Systems

CAHPS^ Health Plan Survey 4.0

Version: Child Commercial Questionnaire

Language: English

Collecting Information about Children With Chronic Conditions. The 4.0 version of the item set for Children With Chronic Conditions has been incorporated into the Child Medicaid Questionnaire (updated July 2007). In that instrument, the items are highlighted in yellow for easy identification.

The Child Commercial Questionnaire includes core items only. Sponsors of this questionnaire are welcome to add the item set for Children With Chronic Conditions and/or other supplemental items.

For more information about the item set, visit https://www.cahps.ahrq.gov/content/products/CCC/PROD_CCC_Intro.asp.

If you have any questions about the use of supplemental items, contact the CAHPS Help Line at [email protected].

File name: 40589901 Last updated: October 6, 2008

Instructions for Front Cover

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

• Include this text regarding the confidentiality of survey responses:

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

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

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

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

• Include this text regarding the burden placed on the public:

Public Burden Statement

We estimate this survey takes an average of 20 minutes to complete including the time for reviewing both the instructions and completed form. Send comments regarding our estimate or any other aspect of this form, including suggestions for reducing completion time, to the Office of Personnel Management (OPM), Insurance Services Programs, Angela Calarco (3206-0236), 1900 E. Street N.W., Washington, DC 20415-7900. The OMB Number 3206-0236 is currently valid. OPM may not collect this information, and you are not required to respond, unless this number is displayed.

• Include the phrase, “OMB Approved: No. 3206-0236” in the upper right corner preferably in a header.

Instructions for Format of Questionnaire

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

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

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

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

Additional guidance is available in Preparing a Questionnaire Using the CAHPS Health Plan Survey: https://www.cahps.ahrq.gov/cahpskit/files/1012_Preparing_Questionnaire_HP40.pdf

Survey Instructions

Answer each question by marking the box to the left of your answer.

You are sometimes told to skip over some questions in this survey. When this happens you will see an arrow with a note that tells you what question to answer next, like this:

Yes  If Yes, go to #1 on page 1

No

Please answer the questions for the child listed on the envelope. Please do not answer for any other children.

1. Our records show that your child is now in {INSERT HEALTH PLAN NAME}. Is that right?

¹ Yes  If Yes, go to #3

² No

2. What is the name of your child’s health plan?

Please print:

Your Child’s Health Care In The Last 12 Months

These questions ask about your child’s health care. Do not include care your child got when he or she stayed overnight in a hospital. Do not include the times your child went for dental care visits.

3. In the last 12 months, did your child have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor’s office?

¹ Yes

² No  If No, go to #5

4. In the last 12 months, when your child needed care right away, how often did your child get care as soon as you thought he or she needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

5. In the last 12 months, not counting the times your child needed care right away, did you make any appointments for your child’s health care at a doctor’s office or clinic?

¹ Yes

² No  If No, go to #7

6. In the last 12 months, not counting the times your child needed care right away, how often did you get an appointment for health care at a doctor’s office or clinic as soon as you thought your child needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

7. In the last 12 months, not counting the times your child went to an emergency room, how many times did he or she go to a doctor’s office or clinic to get health care?

⁰ None  If None, go to #9

¹ 1

² 2

³ 3

⁴ 4

⁵ 5 to 9

⁶ 10 or more

8. Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your child’s health care in the last 12 months?

0 Worst health care possible

1

2

3

4

5

6

7

8

9

10 Best health care possible

Option: Insert additional questions about general health care here.

Your Child’s Personal Doctor

9. A personal doctor is the one your child would see if he or she needs a checkup or gets sick or hurt. Does your child have a personal doctor?

¹ Yes

² No  If No, go to #19 on page 4

10. In the last 12 months, how many times did your child visit his or her personal doctor for care?

⁰ None  If None, go to #18

¹ 1

² 2

³ 3

⁴ 4

⁵ 5 to 9

⁶ 10 or more

11. In the last 12 months, how often did your child’s personal doctor explain things in a way that was easy to understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

12. In the last 12 months, how often did your child’s personal doctor listen carefully to you?

¹ Never

² Sometimes

³ Usually

⁴ Always

13. In the last 12 months, how often did your child’s personal doctor show respect for what you had to say?

¹ Never

² Sometimes

³ Usually

⁴ Always

14. Is your child able to talk with doctors about his or her health care?

¹ Yes

² No  If No, go to #16

15. In the last 12 months, how often did your child’s personal doctor explain things in a way that was easy for your child to understand?

¹ Never

² Sometimes

³ Usually

⁴ Always

16. In the last 12 months, how often did your child’s personal doctor spend enough time with your child?

¹ Never

² Sometimes

³ Usually

⁴ Always

17. In the last 12 months, did your child’s personal doctor talk with you about how your child is feeling, growing, or behaving?

¹ Yes

² No

18. Using any number from 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you use to rate your child’s personal doctor?

0 Worst personal doctor possible

1

2

3

4

5

6

7

8

9

10 Best personal doctor possible

Option: Insert additional questions about personal doctor here.

Getting Health Care From a Specialist

When you answer the next questions, do not include dental visits or care your child got when he or she stayed overnight in a hospital.

19. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 12 months, did you try to make any appointments for your child to see a specialist?

¹ Yes

² No  If No, go to #23

20. In the last 12 months, how often was it easy to get appointments for your child with specialists?

¹ Never

² Sometimes

³ Usually

⁴ Always

21. How many specialists has your child seen in the last 12 months?

⁰ None  If None, go to #23

¹ 1 specialist

² 2

³ 3

⁴ 4

⁵ 5 or more specialists

22. We want to know your rating of the specialist your child saw most often in the last 12 months. Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate that specialist?

0 Worst specialist possible

1

2

3

4

5

6

7

8

9

10 Best specialist possible

Option: Insert additional questions about specialist care here.

Your Child’s Health Plan

23. In the last 12 months, did you try to get any kind of care, tests, or treatment for your child through his or her health plan?

¹ Yes

² No  If No, go to #25

24. In the last 12 months, how often was it easy to get the care, tests, or treatment you thought your child needed through his or her health plan?

¹ Never

² Sometimes

³ Usually

⁴ Always

25. In the last 12 months, did you try to get information or help from customer service at your child’s health plan?

¹ Yes

² No  If No, go to #28

26. In the last 12 months, how often did customer service at your child’s health plan give you the information or help you needed?

¹ Never

² Sometimes

³ Usually

⁴ Always

27. In the last 12 months, how often did customer service staff at your child’s health plan treat you with courtesy and respect?

¹ Never

² Sometimes

³ Usually

⁴ Always

28. In the last 12 months, did your child’s health plan give you any forms to fill out?

¹ Yes

² No  If No, go to #30

29. In the last 12 months, how often were the forms from your child’s health plan easy to fill out?

¹ Never

² Sometimes

³ Usually

⁴ Always

30. Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate your child’s health plan?

0 Worst specialist possible

1

2

3

4

5

6

7

8

9

10 Best specialist possible

Option: Insert additional questions about the health plan here.

About Your Child and You

31. In general, how would you rate your child’s overall health?

¹ Excellent

² Very Good

³ Good

⁴ Fair

⁵ Poor

32. What is your child’s age?

¹ Less than 1 year old

______ YEARS OLD (write in)

33. Is your child male or female?

¹ Male

² Female

34. Is your child of Hispanic or Latino origin or descent?

¹ Yes, Hispanic or Latino

² No, not Hispanic or Latino

35. What is your child’s race? Please mark one or more.

¹ White

² Black or African-American

³ Asian

⁴ Native Hawaiian or other Pacific Islander

⁵ American Indian or Alaska Native

⁶ Other

36. What is your age?

⁰ Under 18

¹ 18 to 24

² 25 to 34

³ 35 to 44

⁴ 45 to 54

⁵ 55 to 64

⁶ 65 to 74

⁷ 75 or older

37. Are you male or female?

¹ Male

² Female

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

¹ 8th grade or less

² Some high school, but did not graduate

³ High school graduate or GED

⁴ Some college or 2-year degree

⁵ 4-year college graduate

⁶ More than 4-year college degree

39. How are you related to the child?

¹ Mother or father

² Grandparent

³ Aunt or uncle

⁴ Older sibling

⁵ Other relative

⁶ Legal guardian

40. Did someone help you complete this survey?

¹ Yes

² No  Thank you.

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

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

¹ Read the questions to me

² Wrote down the answers I gave

³ Answered the questions for me

⁴ Translated the questions into my language

⁵ Helped in some other way

Please print:

Option: Insert other child-specific, member-specific or other general questions here.

Thank you.

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