Appendix B
CAHPS® for Merit-based Incentive Payment System (MIPS) Survey
CAHPS for MIPS Instructions and CATI Script (English)
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 0938-1222 with an expiration date of XX/XX/20XX. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit your documents, please contact Jenny Filipovits at [email protected].
CAHPS® for Merit-based Incentive Payment System
(MIPS) Survey
Instructions for Conducting the Survey via CATI
Overview
This telephone interview script is provided to assist interviewers while attempting to administer the CAHPS for MIPS Survey.
Instructions for Survey Vendors:
• The scripts provided in this document use the same questions as those found in the mail version of the CAHPS for MIPS Survey
• To ensure comparability, neither a group practice nor a survey vendor may change the wording of the survey questions, the response categories, or the order of the questions in any of the surveys
• All text that appears in lowercase letters must be read out loud
• For all questions that use “Never/Sometimes/Usually/Always” response scale, the interviewer should say, “Would you say…,” before reading the response options to the respondent
• Text within a question that is in one of the following styles: underlined, or bolded, or highlighted, or IN UPPERCASE LETTERING, or italicized must be emphasized
• Words that appear in < > are instructions or for informational purposes only and must not be read aloud
• “DON’T KNOW” and “REFUSED” answer categories appear in uppercase and within < > and should not be read to the respondent, but may be used for coding a response
• Text that appears within parentheses and in both (UPPERCASE LETTERING AND ITALICIZED) indicate instructions for the interviewer regarding optional items. These instructions are not to be read aloud. Example: (READ RESPONSE OPTIONS ONLY IF NECESSARY).
• Text that appears within [SQUARE BRACKETS] are used to show programming instructions that must not actually appear on electronic telephone interviewing system screens
• Only one language must appear on the electronic interviewing system screen
• Some items can and should be skipped by certain beneficiaries
o Dependent questions that are appropriately skipped should be coded as “88-NOT APPLICABLE”
• Skip patterns should be programmed into the electronic telephone interviewing system. For example, if a beneficiary answers “No” to a screener question, the program should skip and go to the next screener question. The dependent questions between the screener questions must then be coded as “88-NOT APPLICABLE.” Coding may be done automatically by the telephone interviewing system or later during data preparation.
• When a response to a screener question is not obtained (“98-DON’T KNOW” or “99-REFUSED” are considered responses), the screener question and any questions in the skip pattern should be coded as “M- MISSING.” In this case, the telephone interviewing system should be programmed to skip the dependent question(s) and go to the next screener question. Coding may be done automatically by the telephone interviewing system or later during data preparation.
When a respondent suspends an interview and does not resume, the unanswered screener questions should be coded “M – Missing.”
• Survey vendors may not underline or use bold letters to emphasize words or questions other than what is already included in the final version of the questionnaires provided by CMS
• Please note that the telephone script contains two questions from the questionnaires that ask about receiving assistance (proxy respondent). The questions “Did someone help you complete this survey?” and “How did that person help you?” are to be completed by the interviewer based on the respondent’s (or proxy’s) role during the interview.
• In the event that a beneficiary is unable to complete the interview himself/herself, a proxy interview may be conducted provided the telephone interviewer is able to identify a suitable proxy respondent (someone who knows the beneficiary well and is able to answer health related questions about the beneficiary accurately). However, the telephone interviewer must obtain the beneficiary’s permission to have a proxy respondent assist them with the interview or complete the interview for them. If the interviewer is unable to speak to the beneficiary directly in order to identify a proxy respondent and obtain his/her permission to do the interview for them, they must not proceed with the interview. The CATI introductory script includes a script for identifying and obtaining consent to complete a proxy interview, as well as a reminder for the proxy respondent to answer the survey questions about the beneficiary.
• To ensure that proxy respondents answer survey questions about the beneficiary, all proxy survey questions must be reworded to reference the selected beneficiary:
EXAMPLES:
Q4 In the last 6 months, how many times did [BENEFICIARY NAME] visit this provider to get care for [himself/herself]? Would [he/she] say:
Q45 In the last 6 months, did [BENEFICIARY NAME] try to make any appointments with specialists?
These questions are about [BENEFICIARY NAME] and will help us to describe the people who participate in this survey.
Q57 In general, how would [BENEFICIARY NAME] rate [his/her] overall health? Would [he/she] say:
Instructions for Telephone Interviewer
• Interviewers must ask the survey questions and record the respondent’s responses in a standardized and consistent way, probing as necessary
• Suggested probes are indicated by (PROBE “IF NEEDED: TEXT IS IN ALL UPPER CASE LETTERING.”)
• Characters in < > are instructions or for informational purposes only and must not be read aloud
• Text that appears within parentheses and in both (UPPERCASE LETTERING AND ITALICIZED) indicate instructions for the interviewer regarding optional items. These instructions are not to be read aloud. Example: (READ RESPONSE OPTIONS ONLY IF NECESSARY)
• “DON’T KNOW” and “REFUSED” answer categories appear in uppercase and within < > and should not be read to the respondent, but may be used for coding a response
• Interviewers should read aloud all text that appears in lowercase letters
• Text within a question that is in one of the following styles: underlined, or bolded, or highlighted, or IN UPPERCASE LETTERING, or italicized must be emphasized by the interviewer
• Interviewers must follow basic interviewing conventions such as:
Conducting the interview in a neutral and unbiased fashion
Probing for complete answers in a neutral and professional manner
Reading all questions, transition phrases, and response options exactly as written
Reading all response options in lowercase
Maintaining the integrity of the questionnaire content by asking each question consistently and in the correct order, and without skipping any questions inappropriately
Recording responses accurately
Reading questions at an appropriate speed (at a normal pace, neither too fast, nor too slow)
Repeating questions as necessary
• Interviewers should avoid assuming answers ahead of time, interpreting answers provided, or suggesting answers
• Interviewers should avoid giving their opinion, even when asked; Interviewers should provide positive but neutral feedback to maintain cooperation and to show appreciation for the respondent’s contribution of time and effort.
CATI SCRIPT – NATIONAL IMPLEMENTATION SURVEY
<THE PURPOSE OF THE INTRO1 SCREEN IS TO PROTECT THE PRIVACY OF THE SAMPLED PERSON (SP). THE INTERVIEWER DOES NOT PROVIDE DETAILS ABOUT THE SURVEY UNTIL HE/SHE IS SPEAKING WITH THE SAMPLED PERSON. AT NO POINT DOES THE INTERVIEWER MENTION A PROVIDER NAME TO ANYONE OTHER THAN THE SAMPLED MEMBER. IN ADDITION, NO MESSAGES ARE TO BE LEFT ON AN ANSWERING MACHINE OR VOICE MAIL.>
INTRO1
Hello, may I please speak to [BENEFICIARY NAME]?
(IF NEEDED:) I’m calling to follow up on a letter from Walter Stone of the Centers for Medicare and Medicaid Services (CMS).
1 YES [GO TO INTRO2]
2 SP NOT AVAILABLE RIGHT NOW [GO TO CALLBACK MODULE]
3 REFUSAL [GO TO REFUSAL MODULE]
4 SP NEEDS SPANISH LANGUAGE INTERVIEW [SET LANGUAGE]
5 SP NEEDS CANTONESE INTERVIEW [SET LANGUAGE]
6 SP NEEDS KOREAN INTERVIEW [SET LANGUAGE]
7 SP NEEDS MANDARIN INTERVIEW [SET LANGUAGE]
8 SP NEEDS RUSSIAN INTERVIEW [SET LANGUAGE]
9 SP NEEDS VIETNAMESE INTERVIEW [SET LANGUAGE]
10 SP IS TOO ILL [GO TO PROXY1]
11 SP IS DECEASED [GO TO NON-INTERVIEW
SCREEN]
12 OTHER
NON-INTERVIEW [GO TO NON-INTERVIEW
SCREEN]
PROXY1
I am calling to invite [BENEFICIARY NAME] to take part in an interview about (his/her) experiences with health care. (He/She) can identify someone to complete the interview on (his/her) behalf. I would need to speak with (Mr./Ms.) [BENEFICIARY LAST NAME] briefly about that.
1 YES [GO TO PROXY2]
2 NO [GO TO NON-INTERVIEW
SCREEN]
3 REFUSAL [GO TO REFUSAL MODULE]
PROXY2
My name is [INTERVIEWER NAME] and I’m calling on behalf of the Centers for Medicare & Medicaid Services (CMS) to ask you to take part in an interview about your visits to doctors and nurses in the last 6 months.
If you need help in completing this interview, you can have a family member or close friend help you to answer the questions. If you feel you are unable to complete the interview, you can have a family member or close friend do the interview for you. This person needs to be someone who knows you very well and would be able to accurately answer questions about your visits to doctors and nurses in the last 6 months.
Is there someone who could help you answer the interview, or who could do the interview for you?
1 YES, HELP WITH INTERVIEW [GO TO PROXY3]
2 YES, DO INTERVIEW FOR SP [GO TO PROXY4]
3 NO [GO TO NON-INTERVIEW
SCREEN]
4 REFUSAL [GO TO REFUSAL MODULE]
PROXY3
What is the first name of the person who can help you to answer the interview?
ENTER NAME:
Is that person there right now?
1 YES [GO TO INTRO2]
2 NO, CALL BACK [GO TO CALLBACK MODULE]
[NEED TO INDICATE THIS IS
ASSISTED INTERVIEW]
3 SP UNABLE TO CONTINUE [GO TO NON-INTERVIEW
SCREEN]
4 REFUSAL [GO TO REFUSAL MODULE]
PROXY4
What is the first name of the person who is going to answer the interview on your behalf?
ENTER NAME:
Do I have your permission to conduct the interview with this person on your behalf?
1 YES [GO TO PROXY5]
2 NO, CALL BACK [GO TO CALLBACK MODULE]
3 REFUSAL [GO TO REFUSAL MODULE]
4 SP UNABLE TO CONTINUE [GO TO NON-INTERVIEW
SCREEN]
PROXY5
Is [FILL NAME FROM PROXY4] available to talk with me now?
1 YES [GO TO PROXY6]
2 NO, CALL BACK [GO TO CALLBACK MODULE]
3 REFUSAL [GO TO REFUSAL MODULE]
4 SP UNABLE TO CONTINUE [GO TO NON-INTERVIEW
SCREEN]
PROXY6
(My name is [INTERVIEWER NAME] and I’m calling on behalf of the Centers for Medicare & Medicaid Services (CMS) to ask you to take part in an interview about [BENEFICIARY NAME]’s visits to doctors and nurses in the last 6 months.)
CMS is conducting this study to get direct feedback from Medicare beneficiaries about their experience with the care and services they receive through Medicare. (Mr./Ms.) [BENEFICIARY LAST NAME]’s name was selected at random among people who have visited [PROVIDER NAME]. (He/She) has given permission for you to answer this interview on (his/her) behalf.
This study is voluntary, and your decision to participate or not to participate will not affect (Mr./Ms.) [BENEFICIARY LAST NAME]’s Medicare benefits in any way. The interview will take about 20 minutes to complete, depending on experiences.
[VENDOR NAME] will not share information with anyone other than authorized persons at CMS, except as required by law. Your individual answers will never be seen by (Mr./ Ms.) [BENEFICIARY LAST NAME]’s doctor or anyone else involved with (his/her) care.
Is this a convenient time to answer a few questions?
USE FAQs TO ANSWER QUESTIONS ABOUT THE SURVEY
1 YES [GO TO REMIND]
2 NO [GO TO CALLBACK MODULE]
3 REFUSAL [GO TO REFUSAL MODULE]
REMIND
As you answer the questions in this interview, please remember that you are answering the questions for (Mr./Ms.) [BENEFICIARY LAST NAME]. Please answer the questions based on (his/her) experiences with visits to doctors and nurses.
[GO TO MONITOR]
INTRO2
My name is [INTERVIEWER NAME] and I’m calling on behalf of the Centers for Medicare & Medicaid Services (CMS) to ask you to take part in an interview about your visits to doctors and nurses in the last 6 months.
CMS is conducting this study to get direct feedback from Medicare beneficiaries about their experience with the care and services they receive through Medicare. Your name was selected at random among people who have visited [PROVIDER NAME].
This study is voluntary, and your decision to participate or not to participate will not affect your Medicare benefits in any way. The interview will take about 20 minutes to complete, depending on your experiences.
[VENDOR NAME] will not share your information with anyone other than authorized persons at CMS, except as required by law. Your individual answers will never be seen by your doctor or anyone else involved with your care.
Is this a convenient time to answer a few questions?
USE FAQs TO ANSWER QUESTIONS ABOUT THE SURVEY
1 YES [GO TO MONITOR]
2 NO, CALL BACK [GO TO CALLBACK MODULE]
3 REFUSAL [GO TO REFUSAL MODULE]
4 SP NEEDS SPANISH LANGUAGE INTERVIEW [SET LANGUAGE]
5 SP NEEDS CANTONESE INTERVIEW [SET LANGUAGE]
6 SP NEEDS KOREAN INTERVIEW [SET LANGUAGE]
7 SP NEEDS MANDARIN INTERVIEW [SET LANGUAGE]
8 SP NEEDS RUSSIAN INTERVIEW [SET LANGUAGE]
9 SP NEEDS VIETNAMESE INTERVIEW [SET LANGUAGE]
10 SP IS TOO ILL [GO TO PROXY1]
11 OTHER NON-INTERVIEW [GO TO NON-INTERVIEW
SCREEN]
MONITOR
Before we begin I need to tell you that my supervisor may monitor this call for the purpose of quality control.
<START INTERVIEW>
Q1
Our records show that in the last six months you visited a provider named [PROVIDER NAME].
Is that right?
1 YES
2 NO [GO TO Q44 Intro]
98 <DON’T KNOW> [GO TO Q44 Intro]
99 <REFUSED> [GO TO Q44 Intro]
M [MISSING]
Q2 Intro. The questions in this survey will refer to [PROVIDER NAME] as “this provider.” Please think of that person as you answer the questions.
Q2
Is this the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q3
How long have you been going to this provider? Would you say:
1 Less than 6 months,
2 At least 6 months but less than 1 year,
3 At least 1 year but less than 3 years,
4 At least 3 years but less than 5 years, or
5 5 years or more
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q4 Intro. 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.
Q4
In the last 6 months, how many times did you visit this provider to get care for yourself? Would you say:
0 None [GO TO Q44 Intro]
1 1 time
2 2
3 3
4 4
5 5 to 9, or
6 10 or more times
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q5
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? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q7]
88 [NOT APPLICABLE]
98 <DON’T KNOW> [GO TO Q7]
99 <REFUSED> [GO TO Q7]
M [MISSING]
Q6
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? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q7
In the last 6 months, did you make any appointments for a check-up or routine care with this provider? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q9]
88 [NOT APPLICABLE]
98 <DON’T KNOW> [GO TO Q9]
99 <REFUSED> [GO TO Q9]
M [MISSING]
Q8
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? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q9
In the last 6 months, did you phone this provider’s office with a medical question during regular office hours? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q11]
88 [NOT APPLICABLE]
98 <DON’T KNOW> [GO TO Q11]
99 <REFUSED> [GO TO Q11]
M [MISSING]
Q10
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? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q11
In the last 6 months, did you phone this provider’s office with a medical question after regular office hours? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q13]
88 [NOT APPLICABLE]
98 <DON’T KNOW> [GO TO Q13]
99 <REFUSED> [GO TO Q13]
M [MISSING]
Q12
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? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q13
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? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q15]
88 [NOT APPLICABLE]
98 <DON’T KNOW> [GO TO Q15]
99 <REFUSED> [GO TO Q15]
M [MISSING]
Q14
In the last 6 months, did this provider’s office contact you to remind you to make an appointment for tests or treatment? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q15
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? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q16
In the last 6 months, how often did this provider explain things in a way that was easy to understand? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q17
In the last 6 months, how often did this provider listen carefully to you? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q18
In the last 6 months, did you talk with this provider about any health questions or concerns? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q20]
88 [NOT APPLICABLE]
98 <DON’T KNOW> [GO TO Q20]
99 <REFUSED> [GO TO Q20]
M [MISSING]
Q19
In the last 6 months, how often did this provider give you easy to understand information about these health questions or concerns? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q20
In the last 6 months, how often did this provider seem to know the important information about your medical history? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q21
When you visited this provider in the last 6 months, how often did he or she have your medical records? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
Q22
In the last 6 months, how often did this provider show respect for what you had to say? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q23
In the last 6 months, how often did this provider spend enough time with you? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q24
In the last 6 months, did this provider order a blood test, x-ray, or other test for you? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q26]
88 [NOT APPLICABLE]
98 <DON’T KNOW> [GO TO Q26]
99 <REFUSED> [GO TO Q26]
M [MISSING]
Q25
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? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q26
In the last 6 months, did you and this provider talk about starting or stopping a prescription medicine? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q35]
88 [NOT APPLICABLE]
98 <DON’T KNOW> [GO TO Q35]
99 <REFUSED> [GO TO Q35]
M [MISSING]
Q27
Did you and this provider talk about the reasons you might want to take a medicine? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q28
Did you and this provider talk about the reasons you might not want to take a medicine? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q29
When you and this provider talked about starting or stopping a prescription medicine, did this provider ask what you thought was best for you? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q30
After you and this provider talked about starting or stopping a prescription medicine, did you start a prescription medicine? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q35]
88 [NOT APPLICABLE]
98 <DON’T KNOW> [GO TO Q35]
99 <REFUSED> [GO TO Q35]
M [MISSING]
Q31
In the last 6 months, how often did this provider give you easy to understand instructions about how to take your medicines? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q32
In the last 6 months, other than a prescription, did this provider give you written information or write down information about how to take your medicines? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q34]
88 [NOT APPLICABLE]
98 <DON’T KNOW> [GO TO Q34]
99 <REFUSED> [GO TO Q34]
M [MISSING]
Q33
Was the written information this provider gave you easy to understand? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q34
In the last 6 months, did this provider suggest ways to help you remember to take your medicines? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q35
In the last 6 months, did you and this provider talk about having surgery or any type of procedure? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q39]
88 [NOT APPLICABLE]
98 <DON’T KNOW> [GO TO Q39]
99 <REFUSED> [GO TO Q39]
M [MISSING]
Q36
Did you and this provider talk about the reasons you might want to have the surgery or procedure? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q37
Did you and this provider talk about the reasons you might not want to have the surgery or procedure? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q38
When you and this provider talked about having surgery or a procedure, did this provider ask what you thought was best for you? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q39
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? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q40
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? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q41
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?
ENTER NUMBER: [0-10 valid range]
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q42 Intro. These next questions ask about clerks and receptionists in this provider’s office.
Q42
In the last 6 months, how often were clerks and receptionists at this provider’s office as helpful as you thought they should be? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q43
In the last 6 months, how often did clerks and receptionists at this provider’s office treat you with courtesy and respect? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q44 Intro. These next questions ask about your care from specialists in the last 6 months. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care.
Q44
Is [PROVIDER NAME] a specialist? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES [GO TO Q48 Intro]
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q45
In the last 6 months, did you try to make any appointments with specialists? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q48 Intro]
88 [NOT APPLICABLE]
98 <DON’T KNOW> [GO TO Q48 Intro]
99 <REFUSED> [GO TO Q48 Intro]
M [MISSING]
Q46
In the last 6 months, how often was it easy to get appointments with specialists? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q47
In the last 6 months, how often did the specialist you saw most seem to know the important information about your medical history? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q48 Intro. 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.
Q48
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? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q49
In the last 6 months, did you and anyone on your health care team talk about a healthy diet and healthy eating habits? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q50
In the last 6 months, did you and anyone on your health care team talk about the exercise or physical activity you get? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q51
In the last 6 months, did anyone on your health care team talk with you about specific goals for your health? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q52
In the last 6 months, did you take any prescription medicine? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q55]
98 <DON’T KNOW> [GO TO Q55]
99 <REFUSED> [GO TO Q55]
M [MISSING]
Q53
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? Would you say:
1 Never,
2 Sometimes,
3 Usually, or
4 Always,
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q54
In the last 6 months, did you and anyone on your health care team talk about how much your prescription medicines cost? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q55
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? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q56
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? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q57 Intro. These questions are about you and will help us to describe the people who participate in this survey.
Q57
In general, how would you rate your overall health? Would you say:
1 Excellent
2 Very good
3 Good
4 Fair, or
5 Poor
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q58
In general, how would you rate your overall mental or emotional health? Would you say:
1 Excellent
2 Very good
3 Good
4 Fair, or
5 Poor
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q59
In the last 12 months, have you seen a doctor or other health provider 3 or more times for the same condition or problem? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q61]
98 <DON’T KNOW> [GO TO Q61]
99 <REFUSED> [GO TO Q61]
M [MISSING]
Q60
Is this a condition or problem that has lasted for at least 3 months? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q61
Do you now need or take medicine prescribed by a doctor? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q63]
98 <DON’T KNOW> [GO TO Q63]
99 <REFUSED> [GO TO Q63]
M [MISSING]
Q62
Is this medicine to treat a condition that has lasted for at least 3 months? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q63
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.? Would you say:
1 All of the time,
2 Most of the time,
3 Some of the time,
4 A little of the time, or
5 None of the time
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q64
What is your age?(READ ANSWER CHOICES ONLY IF NEEDED)
1 18 to 24
2 25 to 34
3 35 to 44
4 45 to 54
5 55 to 64
6 65 to 69
7 70 to 74
8 75 to 79
9 80 to 84
10 85 or older
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q65
(INTERVIEWER: ASK ONLY IF NEEDED: Are you male or female?)
1 MALE
2 FEMALE
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q66
What is the highest grade or level of school that you have completed? (READ ANSWER CHOICES ONLY IF NEEDED)
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
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q67
How well do you speak English? Would you say:
1 Very well
2 Well
3 Not well, or
4 Not at all
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q68
Do you speak a language other than English at home? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q70]
98 <DON’T KNOW> [GO TO Q70]
99 <REFUSED> [GO TO Q70]
M [MISSING]
Q69
What is the language you speak at home? (READ ANSWER CHOICES ONLY IF NEEDED)
1 SPANISH
2 CHINESE
3 KOREAN
4 RUSSIAN
5 VIETNAMESE
6 SOME OTHER LANGUAGE [SPECIFY]
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q70
Are you deaf or do you have serious difficulty hearing? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q71
Are you blind or do you have serious difficulty seeing, even when wearing glasses? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q72
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q73
Do you have serious difficulty walking or climbing stairs? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q74
Do you have difficulty dressing or bathing? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q75
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q76
Do you ever use the internet at home? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q77
Are you of Hispanic, Latino, or Spanish origin? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES, HISPANIC, LATINO, OR SPANISH
2 NO, NOT HISPANIC, LATINO, OR SPANISH [GO TO Q79 Intro]
98 <DON’T KNOW> [GO TO Q79 Intro]
99 <REFUSED> [GO TO Q79 Intro]
M [MISSING]
Q78
Which group best describes you? Would you say:
1 Mexican, Mexican American, Chicano
2 Puerto Rican
3 Cuban, or
4 Another Hispanic, Latino, or Spanish origin
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q79 Intro
I am going to read a list of race categories. For each category, please say yes or no if it describes your race. I must ask you about all categories in case more than one applies.
(IF THE RESPONDENT WANTS TO KNOW WHY YOU ARE ASKING WHAT RACE THEY ARE, SAY: “We ask about your race for demographic purposes only.")
Q79a
Are you White? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q79b
(Are you) Black or African American? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q79c
(Are you) American Indian or Alaskan Native? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q79d
(Are you) Asian? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q78e]
98 <DON’T KNOW> [GO TO Q78e]
99 <REFUSED> [GO TO Q78e]
M [MISSING]
Q79d1
(Are you) Asian Indian? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q79d2
(Are you) Chinese? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q79d3
(Are you) Filipino? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q79d4
(Are you) Japanese? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q79d5
(Are you) Korean? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q79d6
(Are you) Vietnamese? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q79d7
(Are you) another Asian race? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q79e
(Are you) Native Hawaiian or Pacific Islander? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO [GO TO Q79]
98 <DON’T KNOW> [GO TO Q79]
99 <REFUSED> [GO TO Q79]
M [MISSING]
Q79e1
(Are you) Native Hawaiian? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q79e2
(Are you) Guamanian or Chamorro? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q79e3
(Are you) Samoan? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q79e4
(Are you) Other Pacific Islander? (READ ANSWER CHOICES ONLY IF NEEDED)
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q80
<INTERVIEWER CODE: DID SOMEONE HELP THE SAMPLED PERSON TO COMPLETE THE INTERVIEW?>
1 YES
2 NO [GO TO END]
98 <DON’T KNOW> [GO TO END]
99 <REFUSED> [GO TO END]
M [MISSING]
Q81a
<How did that person help? Mark one or more.>
<READ THE QUESTIONS TO SAMPLED PERSON>
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q81b
<REPEATED THE ANSWERS SAMPLED PERSON GAVE>
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q81c
<ANSWERED THE QUESTIONS FOR SAMPLED PERSON>
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q81d
<TRANSLATED THE QUESTIONS INTO SAMPLED PERSON’S LANGUAGE>
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
Q81e
<HELPED IN SOME OTHER WAY>
1 YES
2 NO
88 [NOT APPLICABLE]
98 <DON’T KNOW>
99 <REFUSED>
M [MISSING]
END. Those are all the questions I have for you. Thank you for your time.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CMS |
| File Modified | 0000-00-00 |
| File Created | 2021-01-23 |