CMS-10102 HCAHPS Survey Instrument (Mail) and Supporting Materials

OMB Control Number 0938-0981 (Expires: TBD)

HCAHPS Survey
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 1-22 in this survey are part of a national initiative to measure the quality
of care in hospitals. OMB #0938-0981

Please answer the questions in this survey
about your stay at the hospital named on
the cover letter. Do not include any other
hospital stays in your answers.

3.

 Never
 Sometimes
3
 Usually
4
 Always
1
2

YOUR CARE FROM NURSES
1.

During this hospital stay, how often
did nurses treat you with courtesy
and respect?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

2.

During this hospital stay, how often
did nurses listen carefully to you?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

During this hospital stay, how often
did nurses explain things in a way
you could understand?

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
3
 Usually
4
 Always
9
 I never pressed the call button
1
2

1

YOUR CARE FROM DOCTORS
5.

During this hospital stay, how often
did doctors treat you with courtesy
and respect?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

6.

During this hospital stay, how often
did doctors listen carefully to you?

 Never
2
 Sometimes
3
 Usually
4
 Always
1

7.

During this hospital stay, how often
did doctors explain things in a way
you could understand?

 Never
2
 Sometimes
3
 Usually
4
 Always
1

THE HOSPITAL ENVIRONMENT
8.

During this hospital stay, how often
were your room and bathroom kept
clean?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

9.

During this hospital stay, how often
was the area around your room quiet
at night?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

2

YOUR EXPERIENCES IN THIS 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

1

2

11. How often did you get help in getting
to the bathroom or in using a bedpan
as soon as you wanted?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

12. During this hospital stay, were you
given any medicine that you had not
taken before?

 Yes
 No  If No, Go to Question 15

1

2

13. Before giving you any new medicine,
how often did hospital staff tell you
what the medicine was for?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

14. Before giving you any new medicine,
how often did hospital staff describe
possible side effects in a way you
could understand?

 Never
 Sometimes
3
 Usually
4
 Always
1
2

WHEN YOU LEFT THE HOSPITAL
15. 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
3
 Another health
1
2

facility  If Another, Go to
Question 18
16. 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

1
2

17. 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
2
 No
1

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.
18. 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
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
0

Worst hospital possible

1

Best hospital possible

19. Would you recommend this hospital
to your friends and family?
1
 Definitely no
2
 Probably no
3
 Probably yes
4
 Definitely yes

UNDERSTANDING YOUR CARE
WHEN YOU LEFT THE HOSPITAL
20. 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
3
 Agree
4
 Strongly agree
1
2

3

21. When I left the hospital, I had a good
understanding of the things I was
responsible for in managing my
health.
1
 Strongly disagree
2
 Disagree
3
 Agree
4
 Strongly agree
22. When I left the hospital, I clearly
understood the purpose for taking
each of my medications.

 Strongly disagree
 Disagree
3
 Agree
4
 Strongly agree
5
 I was not given any medication when
1

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

 Excellent
 Very good
3
 Good
4
 Fair
5
 Poor
1
2

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

 8th grade or less
 Some high school, but did not

1
2

2

I left the hospital

ABOUT YOU
There are only a few remaining items left.
23. During this hospital stay, were you
admitted to this hospital through the
Emergency Room?

 Yes
 No

1
2

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

 Excellent
2
 Very good
3
 Good
4
 Fair
5
 Poor
1

4



5

6

3
4

graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

27. Are you of Spanish, Hispanic or
Latino origin or descent?

 No, not Spanish/Hispanic/Latino
 Yes, Puerto Rican
3
 Yes, Mexican, Mexican American,
1
2

Chicano
 Yes, Cuban
5
 Yes, other Spanish/Hispanic/Latino
4

28. What is your race? Please choose
one or more.

 White
 Black or African American
3
 Asian
4
 Native Hawaiian or other Pacific
1
2



5

Islander
American Indian or Alaska Native

29. What language do you mainly speak
at home?

 English
 Spanish
3
 Chinese
4
 Russian
5
 Vietnamese
6
 Portuguese
9
 Some other language (please print):
1
2

_____________________

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 1-19 and 23-29 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 20-22) are copyright of Eric A. Coleman, MD, MPH, all rights reserved.

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OMB Paperwork Reduction Act Language
The OMB Paperwork Reduction Act language must be included in the survey mailing. This
language can be either on the front or back of the cover letter or questionnaire, but cannot be a
separate mailing. The following is the language that must be used:
English Version
“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 0938-0981. The time required to complete this
information collected is estimated to average 7 minutes for questions 1-22 on the survey,
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 212441850.”

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