Form 1 CG-CAHPS EZ /CG-CAHPS - English

Attachments for Field Test of Low Literacy Version of
CAHPSÒ Clinician & Group Survey - 0935-0124
Attachment A: English Language Survey and Cover Letters
A1. English Language CG-CAHPS EZ Survey
A2. English Language CG-CAHPS EZ Survey Letters
A3. English Language Standard CG-CAHPS
A4. English Language Standard CG-CAHPS Survey Letters

Form Approved
OMB No. 0935-0124
Exp. Date 11/30/2020

Your Health Care
How do you feel about
your health care?
Please let us know!

This survey is easy to
read and takes about
10 minutes to
complete.

Public reporting burden for this collection of information is estimated to average 10
minutes per response, the estimated time to complete this survey. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. Send comments regarding this
burden estimate or any aspect of this collection of information, including suggestions for
reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork
Reduction Project (0935-0124) AHRQ, 5600 Fishers Lane, #07241A, Rockville, MD 20857.

This Survey is For AltaMed. The survey asks questions about your visits to AltaMed
doctors in the last 6 months. AltaMed is working with the RAND Corporation to collect the
survey. The Agency for Healthcare Research and Quality is paying for the survey.
Help Improve Your Care. AltaMed will use your answers to improve the quality of your
health care.
The Survey is Short. The survey should only take about 10 minutes of your time to
answer.
Your Participation is Voluntary. You may choose to answer this survey or not. If you
choose not to answer the survey, it will not affect the health care you get.
Your Privacy is Protected. All information that would let someone identify you will be
kept private. RAND will not share your personal information with anyone without your
permission.
Your Doctors Don’t See Your Survey. Your responses to this survey are confidential.
RAND will not show your answers to your doctors.
Your Name Won’t be Used. RAND will give AltaMed a summary report using answers
from all the patients who fill out the survey.
What To Do When You’re Done. Once you complete this survey, place it in the
envelope that was provided, seal the envelope, and drop it in the nearest mailbox.

Survey Instructions

Please answer each question
by marking the box
to the left of your answer.
Like this:
Yes
No

Sometimes we ask you to
skip over questions in the survey.
When this happens
you will see an arrow note ®
The arrow note tells you
what question to answer next.
Like this:
Yes
No ® Please go to #1 on page 1

3

In the Last 6 Months

About Your Health Care

4.

Name of Doctor

How many times did you see
this doctor for health care
in the last 6 months?
None ® Please go to #23 on Page 3
1 time
2
3
4
5 to 9
10 or more times

_________________

1. Did you get care from this doctor
in the last 6 months?
1
2

Yes
No ® Please go to #23 on Page 3

5.

Did you contact this doctor’s office
to get care you needed right away
in the last 6 months?
1

Please think of this doctor
When you answer each question

2

6.
2.

How often did you get care
as soon as you needed?
1

Is this the doctor you usually see
for your health care?

2
3

1
2

Yes
No

4

7.
3. How long have you
seen this doctor?
2
3
4
5

Less than 6 months
6 months to about 1 year
1 year to about 3 years
3 years to about 5 years
5 years or more

2

8.

Yes
No ® If No, go to #9 on Next Page

How often did you get an appointment
as soon as you needed?
1
2
3
4

1

Never
Sometimes
Usually
Always

Did you make an appointment
with this doctor for routine care
in the last 6 months?
1

1

Yes
No ® Please go to #7

Never
Sometimes
Usually
Always

In the Last 6 Months
9.

Your Doctor Visits
In the Last 6 Months

Did you contact this doctor
with a medical question
during office hours
in the last 6 months?
1

13. How often did this doctor
explain things
in a way you understood?

Yes
No ® Please go to #11

2

1
2
3
4

10. How often did you get answers
to your medical question
the same day?
1
2
3
4

14. How often did this doctor
listen to you carefully?

Never
Sometimes
Usually
Always

1
2
3
4

11. How often were
clerks and receptionists
as helpful as they should be
in the last 6 months?
1
2
3
4

Never
Sometimes
Usually
Always

1
2
3

12. How often did
clerks and receptionists
treat you with respect
in the last 6 months?
2
3
4

Never
Sometimes
Usually
Always

15. How often did this doctor
seem to know
what is important to you
about your health?

4

1

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

16. How often did this doctor
show respect
for what you had to say?

Never
Sometimes
Usually
Always

1
2
3
4

2

Never
Sometimes
Usually
Always

Your Doctor Visits
In the Last 6 Months

Your Doctor Visits
In the Last 6 Months

17. How often did this doctor
spend enough time with you?

22. Rate the care this doctor gave you
in the last 6 months.
Pick a number from 0 to 10.
The Worst doctor is 0.
The Best doctor is 10.

1
2
3
4

Never
Sometimes
Usually
Always

0 Worst Doctor
1
2
3
4
5
6
7
8
9
10 Best Doctor

18. Did this doctor
order any type of test for you
in the last 6 months?
1
2

Yes
No ® Please go to #20

19. How often did this doctor
explain the test results to you?
1
2
3
4

About Your Health

Never
Sometimes
Usually
Always

23. In general,
how would you rate
your overall physical health?
1

20. Did you take any prescription medicine
in the last 6 months?
1
2

2
3
4

Yes
No ® Please go to #22

5

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

21. How often did this doctor
talk about the medicines you took?
1
2
3
4

Excellent
Very good
Good
Fair
Poor

1

Never
Sometimes
Usually
Always

2
3
4
5

3

Excellent
Very good
Good
Fair
Poor

About You

About You

25. What is your age?

29. What is your race?
Please mark one or more.

1
2
3
4
5
6
7

18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older

1
2
3
4

5

26. Do you currently
describe yourself
as male, female, or transgender?
1
2
3
4

30. Did someone
help you complete
this survey?

Male
Female
Transgender
None of these

1

Yes ® Please go to #31

2

No ® End of Survey. Thank you
Please return the completed
survey in the postage-paid
envelope.

27. What level of school
have you completed?
1
2
3
4
5
6

31. How did that person help you?
Please mark one or more.

8th grade or less
Some high school
High school or GED
Some college
2 or 4-year college degree
Graduate/doctoral degree

1
2
3
4

5

28. Are you Hispanic or Latino?
1
2

White
Black or African American
Asian
Native Hawaiian or Other Pacific
Islander
American Indian or Alaska Native

Yes
No

Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my
language
Helped in some other way
Thank you

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

4

Attachment A2

***LETTER FOR FIRST SURVEY MAILING***

FIRST AND LAST NAME
LINE ONE OF ADDRESS
LINE TWO OF ADDRESS (IF ANY)
CITY, STATE ZIP
Dear {Mr./Ms.} [LAST NAME]
How do you feel about your health care? AltaMed wants you to answer this survey about your
doctor visits in the last 6 months. Your answers will help AltaMed to improve the quality of your
health care. AltaMed is working with the RAND Corporation to collect the survey. The
survey should only take about 10 minutes of your time to answer.
Your Privacy is Protected. All information that would let someone identify you will be kept
private. RAND will not share your personal information with anyone without your permission.
Your Participation is Voluntary. You may choose to answer this survey or not. If you choose
not to answer the survey, it will not affect the health care you get from AltaMed.
Your Doctors Don’t See Your Survey. Your responses to this survey are confidential. RAND
will not show your answers to your doctors.
We hope you answer the survey to let us know how you feel about your health care. Once you
complete this survey, please put it in the enclosed postage-paid envelope and drop it in the
nearest mail box.
If you have any questions about this survey, please call Andrea Moraga Holz at (XXX) [XXXXXXX]. All calls to this number are free. Thank you for helping to make health care at AltaMed
better for everyone!
Sincerely,
Scott Kim, MD
Vice President of Patient Experience
AltaMed Health

***LETTER FOR SECOND SURVEY MAILING***

FIRST AND LAST NAME
LINE ONE OF ADDRESS
LINE TWO OF ADDRESS (IF ANY)
CITY, STATE ZIP
Dear {Mr./Ms.} [LAST NAME]
How do you feel about your health care? AltaMed recently sent you a survey about your
doctor visits in the last 6 months. If you have already returned your survey, thank you for your
help!
If you have not had time to answer the survey, here is another copy. We hope you answer
this survey to help AltaMed to improve the quality of your health care. AltaMed is working with
the RAND Corporation to collect the survey. The survey should only take about 10 minutes of
your time to answer.
Your Privacy is Protected. All information that would let someone identify you will be kept
private. RAND will not share your personal information with anyone without your permission.
Your Participation is Voluntary. You may choose to answer this survey or not. If you choose
not to answer the survey, it will not affect the health care you get from AltaMed.
Your Doctors Don’t See Your Survey. Your responses to this survey are confidential. RAND
will not show your answers to your doctors.
Your feedback is important to AltaMed. Once you complete this survey, please put it in the
enclosed postage-paid envelope and drop it in the nearest mail box.
If you have any questions about this survey, please call Andrea Moraga Holz at (XXX) [XXXXXXX]. All calls to this number are free. Thank you for helping to make health care at AltaMed
better for everyone!
Sincerely,
Scott Kim, MD
Vice President of Patient Experience
AltaMed Health

Attachment A3

Form Approved
OMB No. 0935-0124
Exp. Date 11/30/2020

Your Experiences with Health Care

Public reporting burden for this collection of information is estimated to average 10
minutes per response, the estimated time to complete this survey. An agency may not
conduct or sponsor, and a person is not required to respond to, a collection of information
unless it displays a currently valid OMB control number. Send comments regarding this
burden estimate or any aspect of this collection of information, including suggestions for
reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork
Reduction Project (0935-0124) AHRQ, 5600 Fishers Lane, #07241A, Rockville, MD 20857.

AltaMed is asking you to complete this survey. AltaMed is working with the RAND Corporation, an
independent professional survey organization, to conduct the survey. The survey is funded by the Agency for
Healthcare Research and Quality.
The survey asks about your care from AltaMed in the last 6 months, and should only take about 10 minutes or
less of your time. Altamed will use the information from the survey to learn where and how to improve the
quality of the care they provide.
The survey is voluntary, and it is your decision whether or not to complete the survey. If you decide not to
take part in the survey, your care from AltaMed will not be affected in any way.
The information that you provide will be kept completely private and confidential. Your answers will never
be matched with your name. No one involved in your care will see your individual answers. RAND will
combine your answers with those of other people who complete the survey to create a summary report that tells
AltaMed about patients’ experiences with their providers and medical offices.
AltaMed hopes you answer the survey to share how you feel about your health care. Once you
complete this survey, please put it in the enclosed postage-paid envelope and drop it in the
nearest mail box.

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

Your Provider
1.

Your Care From This Provider in the
Last 6 Months

Our records show that you got care from
the provider named below in the last 6
months.

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.

______________________________

4.

Is that right?
1
2

Yes
No ® If No, go to #23 on page 4

In the last 6 months, how many times did
you visit this provider to get care for
yourself?
None ® If None, go to #23 on
page 4
1 time
2
3
4
5 to 9
10 or more times

The questions in this survey will refer to the
provider named in Question 1 as “this provider.”
Please think of that person as you answer the
survey.
2.

Is this the provider you usually see if you
need a check-up, want advice about a health
problem, or get sick or hurt?
1
2

3.

5.

Yes
No

How long have you been going to this
provider?
1
2
3
4
5

In the last 6 months, did you contact this
provider’s office to get an appointment for
an illness, injury, or condition that needed
care right away?
1
2

Less than 6 months
At least 6 months but less than 1 year
At least 1 year but less than 3 years
At least 3 years but less than 5 years
5 years or more

6.

In the last 6 months, when you contacted
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?
1
2
3
4

1

Yes
No ® If No, go to #7

Never
Sometimes
Usually
Always

7.

In the last 6 months, did you make any
appointments for a check-up or routine
care with this provider?
1
2

11. In the last 6 months, how often did this
provider explain things in a way that was
easy to understand?
1

Yes
No ® If No, go to #9

2
3

8.

1
2
3
4

9.

4

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?

12. In the last 6 months, how often did this
provider listen carefully to you?

Never
Sometimes
Usually
Always

1
2
3
4

In the last 6 months, did you contact this
provider’s office with a medical question
during regular office hours?
1
2

Yes
No ® If No, go to #11

1
2

4

10. In the last 6 months, when you contacted
this provider’s office during regular office
hours, how often did you get an answer to
your medical question that same day?
2
3
4

Never
Sometimes
Usually
Always

13. In the last 6 months, how often did this
provider seem to know the important
information about your medical history?

3

1

Never
Sometimes
Usually
Always

Never
Sometimes
Usually
Always

2

Never
Sometimes
Usually
Always

14. In the last 6 months, how often did this
provider show respect for what you had to
say?
1
2
3
4

18. 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?

Never
Sometimes
Usually
Always

0 Worst provider possible
1
2
3
4
5
6
7
8
9
10 Best provider possible

15. In the last 6 months, how often did this
provider spend enough time with you?
1
2
3
4

Never
Sometimes
Usually
Always

16. In the last 6 months, did this provider order
a blood test, x-ray, or other test for you?
1
2

19. In the last 6 months, did you take any
prescription medicine?

Yes
No ® If No, go to #18

1
2

17. 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?

20. In the last 6 months, how often did you and
someone from this provider’s office talk
about all the prescription medicines you
were taking?
1

1
2
3
4

Yes
No ® If No, go to #21

Never
Sometimes
Usually
Always

2
3
4

3

Never
Sometimes
Usually
Always

Clerks and Receptionists at This
Provider’s Office

About You
23. In general, how would you rate your overall
health?

21. In the last 6 months, how often were clerks
and receptionists at this provider’s office as
helpful as you thought they should be?
1
2
3
4

1
2

Never
Sometimes
Usually
Always

3
4
5

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

22. In the last 6 months, how often did clerks
and receptionists at this provider’s office
treat you with courtesy and respect?
1
2
3
4

Excellent
Very good
Good
Fair
Poor

1
2

Never
Sometimes
Usually
Always

3
4
5

Excellent
Very good
Good
Fair
Poor

25. What is your age?
1
2
3
4
5
6
7

18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older

26. Do you currently describe yourself as male,
female, or transgender?
1
2
3
4

4

Male
Female
Transgender
None of these

27. What is the highest grade or level of school
that you have completed?
1
2

3
4
5
6

30. Did someone help you complete this
survey?
1

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

2

31. How did that person help you? Mark one or
more.

28. Are you of Hispanic or Latino origin or
descent?
1
2

1
2
3

Yes, Hispanic or Latino
No, not Hispanic or Latino

4

5

29. What is your race? Mark one or more.
1
2
3
4

5

Yes
No ® Thank you.
Please return the completed
survey in the postage-paid
envelope.

Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my
language
Helped in some other way

White
Black or African American
Asian
Native Hawaiian or Other Pacific
Islander
American Indian or Alaska Native

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

5

Attachment A4

***LETTER FOR FIRST SURVEY MAILING***

FIRST AND LAST NAME
LINE ONE OF ADDRESS
LINE TWO OF ADDRESS (IF ANY)
CITY, STATE ZIP
Dear {Mr./Ms.} [LAST NAME]

We at AltaMed need your help. Our records indicate that you have visited AltaMed in the
last 6 months, and we would like you to tell us about your care. We are committed to
providing you with the best quality health care available, and your input will help us to
achieve this goal. This brief survey should only take about 10 minutes or less of your time.
The information that you provide will be kept completely private and confidential. Your
answers will never be matched with your name. No one involved in your care will see your
individual answers. We have hired RAND Corporation, an independent professional survey
organization, to conduct the survey. RAND will combine your answers with those of other
people who complete the survey to create a summary report that tells us about our patients’
experiences with our providers and medical offices.
We hope you answer the survey to let us know how you feel about your health care. Once you
complete this survey, please put it in the enclosed postage-paid envelope and drop it in the
nearest mail box.
If you have any questions about this survey, please call Andrea Moraga Holz at (XXX) [XXXXXXX]. All calls to this number are free. Thank you for helping to make health care at AltaMed
better for everyone!
Sincerely,
Scott Kim, MD
Vice President of Patient Experience
AltaMed Health

***LETTER FOR SECOND SURVEY MAILING***

FIRST AND LAST NAME
LINE ONE OF ADDRESS
LINE TWO OF ADDRESS (IF ANY)
CITY, STATE ZIP
Dear {Mr./Ms.} [LAST NAME]

We at AltaMed need your help. Recently, we sent you a survey asking about your
experiences with AltaMed. If you have already responded, we thank you for your feedback.
If you have not had time to respond or you have lost the survey, please take a few minutes to
complete the enclosed survey now. By answering the questions, you will help us to improve
the quality of care we provide our patients. It should take only 10 minutes to answer these
questions.
The information that you provide will be kept completely private and confidential and your
answers will never be matched with your name. No one involved in your care will see your
individual answers.
We hope you will take this chance to tell us about your experiences with health care. You
may choose to participate or not, but the more people who respond, the greater our ability to
improve the quality of care you receive. If you choose not to participate, this will not
affect the health care you get from your providers.
If you have any questions about this survey, please call Andrea Moraga Holz at (XXX) [XXXXXXX]. All calls to this number are free. Thank you for helping to make health care at AltaMed
better for everyone!
Sincerely,
Scott Kim, MD
Vice President of Patient Experience
AltaMed Health