Form CMS-10102 HCAHPS Only ARM, Mode Experiment

HCAHPS INSTRUMENT FOR HCAHPS
ONLY ARM, MODE EXPERIMENT
SURVEY INSTRUCTIONS
You should only fill out this survey if you were the patient during the hospital stay
named in the cover letter. Do not fill out this survey if you were not the patient.
Answer all the questions by checking 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 Question 1

You may notice a number on the survey. This number is used to let us know
if you returned your survey so we don't have to send you reminders.
Please note: Questions 1-25 in this survey are part of a national initiative to
measure the quality of care in hospitals. OMB #0938-0981

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Please answer the questions in this survey about your stay at the hospital named on the
cover letter. Do not include any other stays in your answers.
YOUR CARE FROM NURSES
1. During this hospital stay, how often did nurses treat you with courtesy and respect?
Never
Sometimes
Usually
Always
2. During this hospital stay, how often did nurses listen carefully to you?
Never
Sometimes
Usually
Always
3. During this hospital stay, how often did nurses explain things in a way you could
understand?
Never
Sometimes
Usually
Always
4. During this hospital stay, after you pressed the call button, how often did you get help
as soon as you wanted it?
Never
Sometimes
Usually
Always
I never pressed the call button
YOUR CARE FROM DOCTORS
5. During this hospital stay, how often did doctors treat you with courtesy and respect?
Never
Sometimes
Usually
Always

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6. During this hospital stay, how often did doctors listen carefully to you?
Never
Sometimes
Usually
Always
7. During this hospital stay, how often did doctors explain things in a way you could
understand?
Never
Sometimes
Usually
Always
THE HOSPITAL ENVIRONMENT
8. During this hospital stay, how often were your room and bathroom kept clean?
Never
Sometimes
Usually
Always
9. During this hospital stay, how often was the area around your room quiet at night?
Never
Sometimes
Usually
Always
YOUR EXPERIENCES IN THE HOSPITAL
10. During this hospital stay, did you need help from nurses or other hospital staff in
getting to the bathroom or in using a bedpan?
Yes
No If No, Go to Question 12
11. How often did you get help in getting to the bathroom or in using a bedpan as soon
as you wanted?
Never
Sometimes
Usually
Always
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12. During this hospital stay, did you need medicine for pain?
Yes
No If No, Go to Question 15
13. During this hospital stay, how often was your pain well controlled?
Never
Sometimes
Usually
Always
14. During this hospital stay, how often did the hospital staff do everything they could to
help you with your pain?
Never
Sometimes
Usually
Always
15. During this hospital stay, were you given any medicine that you had not taken
before?
Yes
NoIf No, Go to Question 18
16. Before giving you any new medicine, how often did hospital staff tell you what the
medicine was for?
Never
Sometimes
Usually
Always
17. Before giving you any new medicine, how often did hospital staff describe possible
side effects in a way you could understand?
Never
Sometimes
Usually
Always

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WHEN YOU LEFT THE HOSPITAL
18. After you left the hospital, did you go directly to your own home, to someone else’s
home, or to another health facility?
Own home
Someone else’s home
Another health facility  If Another, Go to Question 21

19. During this hospital stay, did doctors, nurses or other hospital staff talk with you
about whether you would have the help you needed when you left the hospital?
Yes
No
20. During this hospital stay, did you get information in writing about what symptoms or
health problems to look out for after you left the hospital?
Yes
No
OVERALL RATING OF HOSPITAL
Please answer the following questions about your stay at the hospital named on the
cover letter. Do not include any other hospital stays in your answers.
21. Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is the
best hospital possible, what number would you use to rate this hospital during your
stay?
0 Worst hospital possible
1
2
3
4
5
6
7
8
9
10 Best hospital possible

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22. Would you recommend this hospital to your friends and family?
Definitely no
Probably no
Probably yes
Definitely yes
UNDERSTANDING YOUR CARE WHEN YOU LEFT THE HOSPITAL
23. During this hospital stay, staff took my preferences and those of my family or
caregiver into account in deciding what my health care needs would be when I left.
Strongly disagree
Disagree
Agree
Strongly agree

24. When I left the hospital, I had a good understanding of the things I was responsible
for in managing my health.
Strongly disagree
Disagree
Agree
Strongly agree
25. When I left the hospital, I clearly understood the purpose for taking each of my
medications.
Strongly disagree
Disagree
Agree
Strongly agree
I was not given any medication when I left the hospital
ABOUT YOU
There are only a few remaining items left.
26. During this hospital stay, were you admitted to this hospital through the Emergency
Room?
Yes
No

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27. In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
28. In general, how would you rate your overall mental or emotional health?
Excellent
Very good
Good
Fair
Poor
29. 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
30. Are you of Spanish, Hispanic or Latino origin or descent?
No, not Spanish/Hispanic/Latino
Yes, Puerto Rican
Yes, Mexican, Mexican American, Chicano
Yes, Cuban
Yes, other Spanish/Hispanic/Latino
31. What is your race? Please choose one or more.
White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaska Native

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32. What language do you mainly speak at home?
English
Spanish
Chinese
Russian
Vietnamese
Portuguese
Some other language (please print): _____________________

THANK YOU

Please return the completed survey in the postage-paid envelope.
[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]
[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

Questions 1-22 and 26-32 are part of the HCAHPS Survey and are works of the U.S.
Government. These HCAHPS questions are in the public domain and therefore are
NOT subject to U.S. copyright laws. The three Care Transitions Measure® questions
(Questions 23-25) are copyright of The Care Transitions
Program® (www.caretransitions.org).

According to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information unless it displays a valid OMB control
number. The valid OMB control number for this information collection is xxxx-xxxx.
The time required to complete this information collected is estimated to average 8
minutes for questions 1-25, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review the
information collection. If you have any comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: Centers for
Medicare & Medicaid Services, 7500 Security Boulevard, C1-25-05, Baltimore, MD
21244-1850.

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