CMS-10500 Telephone Interview Script for the Outpatient and Ambula

Attachment C:
Introductory Script for Telephone Contact

INTRO1 Hello, may I please speak to [SAMPLE MEMBER’S NAME]?

1. YES Go to INTRO 2 once Sample Member is on phone

2. NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]

3. NO [REFUSAL] Go to TERMINATE Screen

4. MENTALLY/PHYSICALLY INCAPABLE [CODE AS INCAPABLE]

IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [sponsor] on behalf of [FACILITY NAME]. I’d like to speak to [SAMPLE MEMBER’S NAME] about a health care survey.

INTRO2 [Hello, this is [INTERVIEWER NAME] calling on behalf of [FACILITY NAME] [FACILITY NAME] is participating in a survey about patients’ experiences with outpatient surgeries and procedures. The results will be used to help [FACILITY NAME] understand patient experiences in their facilities.

Your participation in this survey is completely voluntary and will not affect any health care or benefits you receive. All information you provide is confidential and is protected by the Privacy Act. The interview will take about 8 minutes to complete. This call may be monitored or recorded for quality improvement purposes.

[ADDRESS ANY QUESTIONS/CONCERNS THEN CONTINUE.]

INTRO3 This survey asks about your experience at [FACILITY NAME]. For this survey, we use the term “procedure” for diagnostic, surgical or other procedures. We refer to “facility” as the place where you had your procedure. Please answer these questions only for the procedure you had on [DATE]. Do not include any other procedures in your answers.

[ADDRESS ANY QUESTIONS/CONCERNS THEN SELECT RESPONSE OPTION.]

1. BEGIN INTERVIEW [GO TO Q1]

2. NO, NOT RIGHT NOW [SET CALLBACK]

3. DID NOT RECEIVE SURGERY/PROCEDURE FROM THIS FACILITY DURING [MONTH]  [GO TO Q_INELIGIBLE SCREEN]

4. NO [REFUSAL] [GO TO Q_REF SCREEN]