Form CMS-10477 Beneficiary survey questionnaire

Attachment 6.c. Survey of Program Participants (English)

<State Program Name>
Survey of Program Participants (12-11-13)

This survey is about a special program for Medicaid beneficiaries in <state>, called the <statewide name> program. You might also know this special program as:

• <specific name>

• <specific name>

• <specific name>

When you answer these questions, please think about your experience in this special program. You could be participating in the program now, or you could have finished the program already.

Some questions ask about the program staff. The program staff can be anyone who helps you as part of the <State Program Name>, such as a [tailored for state: e.g., lifestyle coach, wellness coach, incentives counselor, educator, counselor, nurse, or other health care provider].

The special program could be about different kinds of health issues, such as diabetes prevention, diabetes control, tobacco use, weight management, blood pressure, or cholesterol. The program could be about one health issue or about more than one health issue.

Please follow the instructions in the survey for answering the questions.

Thank you for your time!

Tips for Filling out the Questionnaire

• Please share your honest opinions. All of your answers are kept private. The information is not reported back to program staff

• Please use a BLACK or DARK BLUE ink pen to mark your answers.

• Be sure to read all of the answer choices before marking your answer.

• Sometimes the instruction will say to skip one or more questions. Look for notes telling you whether you should skip a question. If there is no note, go to the next question.

• Answer all questions by putting an “X” in the box next to your answer, like this:

Example

1. In the past month, did you have any headaches?



_ Yes  Go to next question

_ No  Go to Question 3

_ Don’t know  Go to Question 3

2. In the past month, how many times did you have a headache?



_ 12 times

_ 35 times

_ 6 times or more

_ Don’t know

Section A. Satisfaction with the Program

These questions ask about your satisfaction with this special program for Medicaid beneficiaries.

1. How would you rate this program? Choose a number between 1 and 10, where 1 is the worst program possible and 10 is the best program possible.

Worst Best

program program

possible possible

1 2 3 4 5 6 7 8 9 10

2. Would you recommend this program to your family and friends?

Yes, definitely

Yes, probably

No

3. Overall, how satisfied were you with this program?

Very satisfied

Somewhat satisfied

Somewhat dissatisfied

Very dissatisfied

Section B. Experiences with the Program

These questions ask about your experiences with this special program. When you answer these questions, please think about your experiences over the past few months.

Some of the questions ask about the program staff. The program staff can be anyone who helped you as part of this program.

4. How often were you able to contact program staff when you wanted to?

Always

Usually

Sometimes

Never I did not try to contact program staff.

5. The following statements are about the program. [Please answer “yes” or “no” for each.]

	Yes	No
I was able to start the program as soon as I wanted.
The amount of time I spent on the program was about right.
The program schedule was convenient for me.
The program location was convenient for me.
The program staff spoke my language.
I was able to get child care when I needed it to attend the program.			I did not need child care.
I was able to get transportation when I needed it to attend the program.			I did not need transportation.

6. How often were you able to get the help you wanted from the program staff?

Always

Usually

Sometimes

Never

7. Did the program give you any educational materials or information about your health issue(s) (for example, written materials or a website)?

Yes

No  Go to Question 10

8. How helpful were these materials or information?

Very helpful

Somewhat helpful

Not helpful

9. The following statements are about ways the program may have helped you. [Please mark how much you agree or disagree with each statement]

The program….

	Strongly agree	Somewhat agree	Somewhat disagree	Strongly disagree
helped me understand my health issue(s).
helped me learn ways to take better care of my health.
encouraged me to make lifestyle changes to improve my health.

10. The following statements are about your communication with program staff. [Please mark how much you agree or disagree with each statement.]

The program staff…..

	Strongly agree	Somewhat agree	Somewhat disagree	Strongly disagree
explained things in a way I can understand.
listened carefully to what I have to say.
encouraged me to ask questions.
encouraged me to talk about my health concerns.
seemed to care about me as a person.

Section C. Program Rewards or Incentives

These questions ask about any rewards, incentives, or anything else you may have received for participating in this special program. Rewards or incentives could be cash or a debit card, a gift card, points you can use to pick something from a catalog, membership in a gym or health program, or something else.

The program you participated in may not offer all these different types of rewards or incentives.

11. Did you get (or do you expect to get) any rewards or incentives for participating in the program?

Yes

No

Unsure

12. Which kinds of rewards or incentives did you get (or do you expect to get) for participating in the program?

[Please mark Yes or No for each one.]

	Yes	No
Cash or debit card
Gift card
Spending wellness account (for example, a bank account that you can spend on items)
Points you can use to pick something from a catalog
Supplies or medicines that can help you improve your health (for example, a scale, exercise or cooking equipment, nicotine replacement patch)
Activities that can help you improve your health (for example, a gym membership or a Weight Watchers membership, or counseling sessions)
Transportation assistance, child care, or other support to help you participate in the program
Other (please specify): ___________________________________
None.  Go to Section D

13. These statements are about the rewards or incentives for participating in the program.
[Please mark how much you agree or disagree with each statement.]

	Strongly agree	Somewhat agree	Somewhat disagree	Strongly disagree
Rewards or incentives helped me (or will help me) set goals and work toward them.
Rewards or incentives helped me (or will help me) make positive changes in my life.
I like getting rewards or incentives for taking good care of my health.
I am happy with the rewards or incentives.
I am happy with how often I got (or will get) the rewards or incentives.
The rewards or incentives are fair.

Questions about Different Health Issues

The special program could be about different kinds of health issues, such as diabetes prevention, diabetes control, tobacco use, weight management, blood pressure, or cholesterol. The program could be about one health issue or about more than one health issue.

You may be participating in the program now or you could have finished the program already.

Section D. Diabetes Prevention Program

A diabetes prevention program is for people who have a risk of getting diabetes. The purpose of the program is to help people so they don’t get diabetes.

Please answer these questions if the special program you participated in was about diabetes prevention. The program could be about other health issues, too.

14. Was the program you participated in about diabetes prevention?

Yes

No  Go to Section E

15. Did program staff…

	Yes	No
help you learn ways to prevent diabetes?
help you set goals to prevent diabetes?
help you deal with problems that might come up with reaching your goals?
give you medicines to help prevent diabetes?
give you supplies or equipment to help prevent diabetes?

Section E. Diabetes Management Program

A diabetes management program is for people who have been told by a doctor that they have diabetes. The purpose of the program is to help people manage their diabetes.

Please answer these questions if the special program you participated in was about diabetes management. The program could be about other health issues, too.

16. Was the program you participated in about diabetes management?

Yes

No  Go to Section F

17. Did program staff…

	Yes	No
help you learn ways to manage your diabetes?
help you set goals to manage your diabetes?
help you deal with problems that might come up with reaching your goals?
give you medicines to help manage your diabetes?
give you supplies or equipment to help manage your diabetes?

Section F. Tobacco Program

A tobacco program can help people quit smoking or using other kinds of tobacco.

Please answer these questions if the special program you participated in was about quitting smoking or using other kinds of tobacco. The program could be about other health issues, too.

18. Was the program you participated in about quitting smoking or using other kinds of tobacco?

Yes

No  Go to Section G

19. Did program staff…

	Yes	No
help you learn ways to quit using tobacco?
help you set goals to quit using tobacco?
help you deal with problems that might come up reaching your goals?
give you medicines to help you quit using tobacco?
give you supplies or equipment to help you quit using tobacco?

Section G. Weight Management Program

A weight management program can help people manage their weight or help them lose weight.

Please answer these questions if the special program you participated in was about weight management. The program could be about other health issues, too.

20. Was the program you participated in about weight management?

Yes

No  Go to Section H

21. Did program staff…

	Yes	No
help you learn ways to manage your weight or lose weight?
help you set goals to manage your weight or lose weight?
help you deal with problems that might come up with reaching your goals?
give you medicines to help with your weight?
give you supplies or equipment to help with your weight?

Section H. Blood Pressure Program

A blood pressure program can help people manage or lower their blood pressure.

Please answer these questions if the special program you participated in was about blood pressure. The program could be about other health issues, too.

22. Was the program you participated in about blood pressure?

Yes

No  Go to Section I

23. Did program staff…

	Yes	No
help you learn ways to manage your blood pressure?
help you set goals to manage your blood pressure?
help you deal with problems that might come up with reaching your goals?
give you medicines to help you with your blood pressure?
give you supplies or equipment to help you with your blood pressure?

Section I. Cholesterol Program

A cholesterol program can help people manage their cholesterol or lower their cholesterol.

Please answer these questions if the special program you participated in was about managing your cholesterol. The program could be about other health issues, too.

24. Was the program you participated in about cholesterol?

Yes

No  Go to Section J

25. Did program staff…

	Yes	No
help you learn ways to lower your cholesterol?
help you set goals to lower your cholesterol?
help you deal with problems that might come up with reaching your goals?
give you medicines to help lower your cholesterol?
give you supplies or equipment to help lower your cholesterol?

Section J. About You

These questions ask about your background.

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

Excellent

Very good

Good

Fair

Poor

27. In general, how would you rate your overall mental or emotional health?

Excellent

Very good

Good

Fair

Poor

28. What year were you born?

___________________

29. What is your sex?

Male

Female

30. What is your marital status?

Now married or living with a partner

Widowed

Divorced

Separated

Never married

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

8^th grade or less

Some high school, but did not graduate

High school graduate or GED

Some college or 2-year college degree

4-year college degree

More than 4-year college degree

32. What is your current employment status? [Mark all that apply.]

Employed full-time

Employed part-time

Unemployed and looking for work

Student

Homemaker

Retired

Other (please specify):

33. Are you of Hispanic or Latino origin or descent?

Yes, Hispanic or Latino

No, not Hispanic or Latino

34. What is your race? [Mark all that apply.]

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

35. Did someone help you complete this survey?

Yes

No  Go to Question 37

36. How did that person help you? [Mark all that apply.]

Answered some or all of the questions for me

Read the questions to me

Explained the questions to me

Wrote down the answers I gave

Translated the questions into my language

Helped in some other way, please specify:

37. If you have more comments about the program, please write them here.

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Thank you!

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