CMS-10537 CAHPS Hospice Survey - Telephone

OMB Control Number: 0938-1257
Expiration Date: XX/XXXX

CAHPS Hospice Survey
Telephone Script (English)
Overview
This telephone interview script is provided to assist interviewers while attempting to reach the
caregiver of the sampled decedent. The script explains the purpose of the survey and confirms
necessary information about the caregiver and decedent.
General Interviewing Conventions and Instructions
 The telephone introduction script must be read verbatim
 All text that appears in lowercase letters must be read out loud
 Text in UPPERCASE letters must not be read out loud
 YES and NO response options are only to be read if necessary
Note: It is not permissible to capitalize underlined content, as text that appears in
uppercase letters throughout the CATI script must not be read out loud. Survey vendors
are permitted to emphasis underlined content in a different manner if underlining is not a
viable option, such as placing quotes (“”) or asterisks (**) around the emphasized
content.
 All questions and all answer categories must be read exactly as they are worded
 During the course of the survey, use of neutral acknowledgment words such as the
following is permitted:
o Thank you
o Alright
o Okay
o I understand, or I see
o Yes, Ma’am
o Yes, Sir
 Read the scripts from the interviewer screens (reciting the survey from memory can lead to
unnecessary errors and missed updates to the scripts)
 Adjust the pace of the CAHPS Hospice Survey interview to be conducive to the needs of the
respondent
 No changes are permitted to the order of the question and answer categories for the “Core,”
“About Your Family Member” and “About You” CAHPS Hospice Survey questions
 The first forty “ Core” questions must remain together
 The three “About Your Family Member” questions must remain together
 The four “About You” questions must remain together
 All transitional statements must be read
 Text that is underlined must be emphasized
 Characters in < > must not be read
 [Square brackets] are used to show programming instructions that must not actually appear
on electronic telephone interviewing system screens

December 2016

1

 Only one language (i.e., English or Spanish) can appear on the electronic interviewing
system screen
 MISSING/DON’T KNOW (DK) is a valid response option for each item in the electronic
telephone interviewing system scripts. This allows the telephone interviewer to go to the next
question if a caregiver is unable to provide a response for a given question (or refuses to
provide a response). In the survey file layouts, a value of “MISSING/DK” is coded as “M –
Missing/Don't Know.”
 Skip patterns should be programmed into the electronic telephone interviewing system
 Appropriately skipped questions should be coded as “88 – Not Applicable.” For example,
if a patient answers “No” to Question 4 of the CAHPS Hospice Survey, the program
should skip Question 5, and go to Question 6. Question 5 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, the screener question and any
questions in the skip pattern should be coded as “M – Missing/Don't Know.” For
example, if the patient does not provide an answer to Question 4 of the CAHPS Hospice
Survey and the interviewer selects “M – Missing/Don’t Know” to Question 4, then the
telephone interviewing system should be programmed to skip Question 5, and go to
Question 6. Question 5 must then be coded as “M – Missing/Don't Know.” Coding may
be done automatically by the telephone interviewing system or later during data
preparation.

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December 2016

INITIATING CONTACT
START:

Hello, may I please speak to [SAMPLED CAREGIVER NAME]?
<1> YES [GO TO INTRO]
<2> PROXY IDENTIFIED [COLLECT PROXY INFORMATION THEN
RETURN TO INTRO]
<3> NO, REFUSAL [GO TO REFUSAL]
<4> NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]
<5> ALREADY RETURNED SURVEY BY MAIL [GO TO MAILED]
<6> PATIENT DIDN’T RECEIVE CARE AT NAMED HOSPICE [GO TO
DISAVOWAL]
IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [VENDOR NAME]. We are
working with [HOSPICE NAME] and the U.S. Department of Health and
Human Services to conduct a survey about hospice care.
IF THE SAMPLED CAREGIVER IS NOT AVAILABLE:
Can you tell me a convenient time to call back to speak with (him/her)?
IF THE SAMPLED CAREGIVER SAYS THIS IS NOT A GOOD TIME:
If you don’t have the time now, when is a more convenient time to call you
back?
IF SOMEONE OTHER THAN THE SAMPLED CAREGIVER ANSWERS
THE PHONE, RECONFIRM THAT YOU ARE SPEAKING WITH THE
SAMPLED CAREGIVER WHEN HE OR SHE PICKS UP.

******

December 2016

3

INITIATING CONTACT WITH A PROXY RESPONDENT
START:

Hello, may I please speak to [PROXY CAREGIVER NAME]?
<1> YES [GO TO INTRO]
<2> NO [GO TO REFUSAL]
<3> NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]
IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [VENDOR NAME]. We are
working with [HOSPICE NAME] and the U.S. Department of Health and
Human Services to conduct a survey about hospice care.
IF THE PROXY CAREGIVER IS NOT AVAILABLE:
Can you tell me a convenient time to call back to speak with (him/her)?
IF THE PROXY CAREGIVER SAYS THIS IS NOT A GOOD TIME:
If you don’t have the time now, when is a more convenient time to call you
back?
IF SOMEONE OTHER THAN THE PROXY CAREGIVER ANSWERS THE
PHONE, RECONFIRM THAT YOU ARE SPEAKING WITH THE PROXY
CAREGIVER WHEN HE OR SHE PICKS UP.

******
CALL BACK TO COMPLETE A PREVIOUSLY STARTED SURVEY
START:

Hello, may I please speak to [SAMPLED CAREGIVER NAME/PROXY
CAREGIVER NAME]?
<1> YES [GO TO CONFIRM RESPONDENT]
<2> NO [REFUSAL]
<3> NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]
IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [SURVEY VENDOR]. Is
[SAMPLED CAREGIVER NAME/PROXY CAREGIVER NAME] available
to complete a survey that [HE/SHE] started at an earlier date?
CONFIRM RESPONDENT: Before we continue with the survey, I would like
to confirm that I am speaking with [SAMPLED CAREGIVER NAME/PROXY
CAREGIVER NAME].
CONTINUE SURVEY WHERE PREVIOUSLY LEFT OFF.

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December 2016

SPEAKING WITH CAREGIVER
INTRO

Hi, my name is [INTERVIEWER NAME] and I’m calling from [VENDOR
NAME].
[HOSPICE NAME] is conducting a survey about the hospice services that
patients and their families receive. It is part of a national initiative sponsored by
the United States Department of Health and Human Services to measure the
quality of care in hospices. We realize this may be a difficult time for you, but we
hope that you will take a few minutes to help us learn about the quality of hospice
care that you and your loved one received.
Your participation is voluntary and will not affect any health care or benefits you
receive. The interview will take [FILL: approximately 11 minutes/SURVEY
VENDOR SPECIFY]. Your answers will be combined with other respondents
and shared with the hospice for purposes of quality improvement.
IF ASKED WHETHER SOMEONE ELSE CAN SERVE AS PROXY FOR
SAMPLED CAREGIVER:
For this survey, we need to speak to the person in your household who is the
most knowledgeable about the hospice care received by [DECEDENT
NAME]. ONCE THE MOST KNOWLEDGEABLE PERSON’S NAME IS
PROVIDED: [Is he/she OR are you] the most knowledgeable about the
hospice care received by [DECEDENT NAME]?
IF NEEDED AND SPEAKING WITH THE SAMPLED CAREGIVER:
We received your name from [HOSPICE NAME] because you were listed as
the caregiver for [DECEDENT NAME].
IF NEEDED AND SPEAKING WITH PROXY FOR SAMPLED
CAREGIVER: We received your name from [SAMPLED CAREGIVER]
because he/she indicated that you were knowledgeable about the hospice care
received by [DECEDENT NAME].
<1> YES [GO TO CONTINUE]
<2> PROXY IDENTIFIED [COLLECT PROXY INFORMATION, THEN
RETURN TO PROXY INTRO]
<3> NO, WILL RETURN COMPLETED MAILED SURVEY [GO TO
CALLBACK]
<4> NO, CALL BACK [GO TO CALLBACK]
<5> NO, OR UNAVAILABLE DURING FIELD PERIOD [GO TO ITEM TO
CODE INELIGIBLE, ETC.,]
<6> REFUSE [GO TO REFUSAL]
<7> ALREADY RETURNED SURVEY BY MAIL [GO TO MAILED]
<8> NOT INVOLVED IN CARE AND NO PROXY IDENTIFIED [GO TO
INELIGIBLE]
<9> PATIENT DIDN’T RECEIVE CARE AT NAMED HOSPICE [GO TO
DISAVOWAL]

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*******
CONTINUE
This call may be monitored [OPTIONAL: and/or recorded] for quality
improvement purposes. May we begin?
<1> YES [BEGIN SURVEY]
<2> NO, CALL BACK [GO TO CALLBACK]
<3> REFUSE [GO TO REFUSAL]
*******
MAILED
Thank you so much for completing the survey by mail. Perhaps we still have not
gotten it but we’ll check our records again. We may need to contact you again in
case we still have not received it. [END CALL]
*******
INELIGIBLE
I’m sorry, for this project we are only speaking with family members or friends
who took part in or oversaw hospice care for their family members. Thank you for
your time. Have a good (day/evening). [END CALL]
*******
DISAVOWAL
Perhaps there was an error in our records. Thank you for your time. Have a good
(day/evening). [END CALL]

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December 2016

BEGIN CAHPS HOSPICE SURVEY QUESTIONS
Q1_INTRO

Please answer all questions in this survey about the care the patient received at
[HOSPICE NAME]. When thinking about your answers, do not include any other
hospice stays.
BE PREPARED TO PROBE IF THE CAREGIVER ANSWERS OUTSIDE OF
THE ANSWER CATEGORIES PROVIDED. PROBE BY REPEATING THE
ANSWER CATEGORIES ONLY; DO NOT INTERPRET FOR THE
CAREGIVER.

Q1

How are you related to [DECEDENT NAME]?
READ ANSWER CHOICES ONLY IF NECESSARY

Q1A

<1> MY SPOUSE OR PARTNER
<2> MY PARENT
<3> MY MOTHER-IN-LAW
OR FATHER-IN-LAW
<4> MY GRANDPARENT
<5> MY AUNT OR UNCLE
<6> MY SISTER OR BROTHER
<7> MY CHILD
<8> MY FRIEND
<9> OTHER (PLEASE SPECIFY)

[GO TO Q2]
[GO TO Q2]

MISSING/DK

[GO TO Q2]

[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q2]
[GO TO Q1A]

How are you related to [DECEDENT NAME]?
NOTE: PLEASE DOCUMENT THE RELATIONSHIP AND MAINTAIN IN
YOUR INTERNAL RECORDS.

[NOTE: FOR TELEPHONE INTERVIEWING, Q2 IS BROKEN INTO PARTS A – G.]
Q2

For this survey, the phrase “family member” refers to [DECEDENT NAME].
Please answer yes or no to each of the categories. I am required to read all six
categories. In what locations did your family member receive care from
[HOSPICE NAME]?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

Q2A

At home?
<1> YES
<0> NO
MISSING/DK

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Q2B

At an assisted living facility?
<1> YES
<0> NO
MISSING/DK

Q2C

At a nursing home?
<1> YES
<0> NO
MISSING/DK

Q2D

At a hospital?
<1> YES
<0> NO
MISSING/DK

Q2E

At a hospice facility or hospice house?
<1> YES
<0> NO
MISSING/DK

Q2F

Q2G

At some other place?
<1> YES
<0> NO

[GO TO Q2G]
[GO TO Q3]

MISSING/DK

[GO TO Q3]

Where did your family member receive care?
NOTE: PLEASE DOCUMENT THE OTHER PLACE AND MAINTAIN IN
YOUR INTERNAL RECORDS.

8

December 2016

Q3

While your family member was in hospice care, how often did you take part in or
oversee care for him or her? Would you say…
<1>
<2>
<3>
<4>

Never,
Sometimes,
Usually, or
Always?

[GO TO Q41_INTRO]

MISSING/DK
Q4_INTRO

As you answer the rest of the questions in this survey, please think only about
your family member's experience with [HOSPICE NAME].

Q4

For this survey, the hospice team includes all the nurses, doctors, social workers,
chaplains and other people who provided hospice care to your family member.
While your family member was in hospice care, did you need to contact the
hospice team during evenings, weekends, or holidays for questions or help with
your family member’s care?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

Q5

<1> YES
<2> NO

[GO TO Q6]

[<88> NOT APPLICABLE]
MISSING/DK

[GO TO Q6]

How often did you get the help you needed from the hospice team during
evenings, weekends, or holidays? Would you say…
<1> Never,
<2> Sometimes,
<3> Usually, or
<4> Always?
[<88> NOT APPLICABLE]
MISSING/DK

December 2016

9

Q6

While your family member was in hospice care, how often did the hospice team
keep you informed about when they would arrive to care for your family
member? Would you say…
<1> Never,
<2> Sometimes,
<3> Usually, or
<4> Always?
[<88> NOT APPLICABLE]
MISSING/DK

Q7

While your family member was in hospice care, when you or your family member
asked for help from the hospice team, how often did you get help as soon as you
needed it? Would you say…
<1> Never,
<2> Sometimes,
<3> Usually, or
<4> Always?
[<88> NOT APPLICABLE]
MISSING/DK

Q8

While your family member was in hospice care, how often did the hospice team
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]
MISSING/DK

Q9

While your family member was in hospice care, how often did the hospice team
keep you informed about your family member’s condition? Would you say…
<1> Never,
<2> Sometimes,
<3> Usually, or
<4> Always?
[<88> NOT APPLICABLE]
MISSING/DK

10

December 2016

Q10

While your family member was in hospice care, how often did anyone from the
hospice team give you confusing or contradictory information about your family
member’s condition or care? Would you say…
<1> Never,
<2> Sometimes,
<3> Usually, or
<4> Always?
[<88> NOT APPLICABLE]
MISSING/DK

Q11

While your family member was in hospice care, how often did the hospice team
treat your family member with dignity and respect? Would you say…
<1> Never,
<2> Sometimes,
<3> Usually, or
<4> Always?
[<88> NOT APPLICABLE]
MISSING/DK

Q12

While your family member was in hospice care, how often did you feel that the
hospice team really cared about your family member? Would you say…
<1> Never,
<2> Sometimes,
<3> Usually, or
<4> Always?
[<88> NOT APPLICABLE]
MISSING/DK

Q13

While your family member was in hospice care, did you talk with the hospice
team about any problems with your family member’s hospice care?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
NOTE: IF THE RESPONDENT REPLIES, “I DIDN’T HAVE ANY
PROBLEMS,” CODE RESPONSE AS “NO.”
<1> YES
<2> NO

[GO TO Q15]

[<88> NOT APPLICABLE]
MISSING/DK

[GO TO Q15]

December 2016

11

Q14

How often did the hospice team listen carefully to you when you talked with them
about problems with your family member’s hospice care? Would you say…
<1> Never,
<2> Sometimes,
<3> Usually, or
<4> Always?
[<88> NOT APPLICABLE]
MISSING/DK

Q15

While your family member was in hospice care, did he or she have any pain?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

Q16

<1> YES
<2> NO

[GO TO Q17]

[<88> NOT APPLICABLE]
MISSING/DK

[GO TO Q17]

Did your family member get as much help with pain as he or she needed? Would
you say…
<1> Yes, definitely,
<2> Yes, somewhat, or
<3> No?
[<88> NOT APPLICABLE]
MISSING/DK

Q17

While your family member was in hospice care, did he or she receive any pain
medicine?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

12

<1> YES
<2> NO

[GO TO Q21]

[<88> NOT APPLICABLE]
MISSING/DK

[GO TO Q21]

December 2016

Q18

Side effects of pain medicine include things like sleepiness. Did any member of
the hospice team discuss side effects of pain medicine with you or your family
member? Would you say…
<1> Yes, definitely,
<2> Yes, somewhat, or
<3> No?
[<88> NOT APPLICABLE]
MISSING/DK

Q19

Did the hospice team give you the training you needed about what side effects to
watch for from pain medicine? Would you say…
<1> Yes, definitely,
<2> Yes, somewhat, or
<3> No?
[<88> NOT APPLICABLE]
MISSING/DK

Q20

Did the hospice team give you the training you needed about if and when to give
more pain medicine to your family member? Would you say…
<1> Yes, definitely,
<2> Yes, somewhat,
<3> No, or
<4> I did not need to give pain medicine to my family member.
[<88> NOT APPLICABLE]
MISSING/DK

Q21

While your family member was in hospice care, did your family member ever
have trouble breathing or receive treatment for trouble breathing?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
<1> YES
<2> NO

[GO TO Q24]

[<88> NOT APPLICABLE]
MISSING/DK

[GO TO Q24]

December 2016

13

Q22

How often did your family member get the help he or she needed for trouble
breathing? Would you say…
<1> Never,
<2> Sometimes,
<3> Usually, or
<4> Always?
[<88> NOT APPLICABLE]
MISSING/DK

Q23

Did the hospice team give you the training you needed about how to help your
family member if he or she had trouble breathing? Would you say…
<1> Yes, definitely,
<2> Yes, somewhat,
<3> No, or
<4> I did not need to help my family member with trouble breathing.
[<88> NOT APPLICABLE]
MISSING/DK

Q24

While your family member was in hospice care, did your family member ever
have trouble with constipation?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

Q25

<1> YES
<2> NO

[GO TO Q26]

[<88> NOT APPLICABLE]
MISSING/DK

[GO TO Q26]

How often did your family member get the help he or she needed for trouble with
constipation? Would you say...
<1> Never,
<2> Sometimes,
<3> Usually, or
<4> Always?
[<88> NOT APPLICABLE]
MISSING/DK

14

December 2016

Q26

While your family member was in hospice care, did he or she show any feelings
of anxiety or sadness?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

Q27

<1> YES
<2> NO

[GO TO Q28]

[<88> NOT APPLICABLE]
MISSING/DK

[GO TO Q28]

How often did your family member get the help he or she needed from the
hospice team for feelings of anxiety or sadness? Would you say…
<1> Never,
<2> Sometimes,
<3> Usually, or
<4> Always?
[<88> NOT APPLICABLE]
MISSING/DK

Q28

While your family member was in hospice care, did he or she ever become
restless or agitated?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

Q29

<1> YES
<2> NO

[GO TO Q30]

[<88> NOT APPLICABLE]
MISSING/DK

[GO TO Q30]

Did the hospice team give you the training you needed about what to do if your
family member became restless or agitated? Would you say…
<1> Yes, definitely,
<2> Yes, somewhat, or
<3> No?
[<88> NOT APPLICABLE]
MISSING/DK

December 2016

15

Q30

Moving your family member includes things like helping him or her turn over in
bed, or get in and out of bed or a wheelchair. Did the hospice team give you the
training you needed about how to safely move your family member? Would you
say…
<1> Yes, definitely,
<2> Yes, somewhat,
<3> No, or
<4> I did not need to move my family member.
[<88> NOT APPLICABLE]
MISSING/DK

Q31

Did the hospice team give you as much information as you wanted about what to
expect while your family member was dying? Would you say…
<1> Yes, definitely,
<2> Yes, somewhat, or
<3> No?
[<88> NOT APPLICABLE]
MISSING/DK

Q32

Some people receive hospice care while they are living in a nursing home. Did
your family member receive care from this hospice while he or she was living in a
nursing home?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

Q33

<1> YES
<2> NO

[GO TO Q35]

[<88> NOT APPLICABLE]
MISSING/DK

[GO TO Q35]

While your family member was in hospice care, how often did the nursing home
staff and hospice team work well together to care for your family member?
Would you say…
<1> Never,
<2> Sometimes,
<3> Usually, or
<4> Always?
[<88> NOT APPLICABLE]
MISSING/DK

16

December 2016

Q34

While your family member was in hospice care, how often was the information
you were given about your family member by the nursing home staff different
from the information you were given by the hospice team? Would you say…
<1> Never,
<2> Sometimes,
<3> Usually, or
<4> Always?
[<88> NOT APPLICABLE]
MISSING/DK

Q35_INTRO The next set of questions is about you.
Q35

While your family member was in hospice care, how often did the hospice team
listen carefully to you? Would you say…
<1> Never,
<2> Sometimes,
<3> Usually, or
<4> Always?
[<88> NOT APPLICABLE]
MISSING/DK

Q36

Support for religious or spiritual beliefs includes talking, praying, quiet time, or
other ways of meeting your religious or spiritual needs. While your family
member was in hospice care, how much support for your religious and spiritual
beliefs did you get from the hospice team? Would you say…
<1> Too little,
<2> The right amount, or
<3> Too much?
[<88> NOT APPLICABLE]
MISSING/DK

Q37

While your family member was in hospice care, how much emotional support did
you get from the hospice team? Would you say…
<1> Too little,
<2> The right amount, or
<3> Too much?
[<88> NOT APPLICABLE]
MISSING/DK

December 2016

17

Q38

In the weeks after your family member died, how much emotional support did
you get from the hospice team? Would you say…
<1> Too little,
<2> The right amount, or
<3> Too much?
[<88> NOT APPLICABLE]
MISSING/DK

Q39

Please answer the following questions about your family member’s care from
[HOSPICE NAME]. Do not include care from other hospices in your answers.
Using any number from 0 to 10, where 0 is the worst hospice care possible and 10
is the best hospice care possible, what number would you use to rate your family
member’s hospice care?
IF THE RESPONDENT DOES NOT PROVIDE AN APPROPRIATE
RESPONSE, PROBE BY REPEATING: Using any number from 0 to 10, where 0
is the worst hospice care possible and 10 is the best hospice care possible, what
number would you use to rate your family member’s hospice care?
READ ANSWER CHOICES ONLY IF NECESSARY
<0> 0
<1> 1
<2> 2
<3> 3
<4> 4
<5> 5
<6> 6
<7> 7
<8> 8
<9> 9
<10> 10
[<88> NOT APPLICABLE]
MISSING/DK

18

December 2016

Q40

Would you recommend this hospice to your friends and family? Would you say…
<1> Definitely no,
<2> Probably no,
<3> Probably yes, or
<4> Definitely yes?
[<88> NOT APPLICABLE]
MISSING/DK

Q41_INTRO The next questions are about your family member.
Q41

What is the highest grade or level of school that your family member completed?
[OPTIONAL: Did he or she…]
READ ANSWER CHOICES ONLY IF NECESSARY
<1> Complete 8th grade or less,
<2> Complete some high school, but did not graduate,
<3> Graduate from high school or earn a GED,
<4> Complete some college or earn a 2-year degree,
<5> Graduate from a 4-year college, or
<6> Complete more than a 4-year college degree?
<7> RESPONDENT INDICATES THAT HE OR SHE DOES NOT
KNOW FAMILY MEMBER’S LEVEL OF EDUCATION
MISSING
ACADEMIC TRAINING BEYOND A HIGH SCHOOL DIPLOMA THAT
DOES NOT LEAD TO A BACHELORS DEGREE SHOULD BE CODED AS 4.
IF THE RESPONDENT DESCRIBES NON-ACADEMIC TRAINING, SUCH
AS TRADE SCHOOL, PROBE TO FIND OUT IF THE FAMILY MEMBER
HAS A HIGH SCHOOL DIPLOMA AND CODE 2 OR 3, AS APPROPRIATE.

December 2016

19

Q42

Was your family member of Hispanic, Latino, or Spanish origin or descent?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
YES
<1> NO
MISSING/DK
IF YES: Would you say your family member was (READ ALL RESPONSE
CHOICES)
<2> Puerto Rican,
<3> Mexican, Mexican American, Chicano/a,
<4> Cuban, or
<5> Other Spanish/Hispanic/Latino?
MISSING/DK

[NOTE: FOR TELEPHONE INTERVIEWING, QUESTION 43 IS BROKEN INTO PARTS
A – E.]
Q43

When I read the following, please tell me if the category describes your family
member’s race. I am required to read all five categories. Please answer yes or no
to each of the categories.
READ ALL RACE CATEGORIES PAUSING AT EACH RACE CATEGORY
TO ALLOW CAREGIVER TO REPLY TO EACH RACE CATEGORY.
IF THE RESPONDENT REPLIES, “WHY ARE YOU ASKING ABOUT MY
FAMILY MEMBER’S RACE?:” We ask about your family member’s race for
demographic purposes. We want to make sure that the people we include
accurately represent the racial diversity in this country.
IF THE RESPONDENT REPLIES, “I ALREADY TOLD YOU ABOUT MY
FAMILY MEMBER’S RACE:” I understand, however the survey requires me to
ask about all races so results can include people who are multiracial. If the race
does not apply to your family member please answer no. Thanks for your
patience.
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

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December 2016

Q43A

Was your family member White?
<1> YES/WHITE
<0> NO/NOT WHITE
MISSING/DK

Q43B

Was your family member Black or African American?
<1> YES/BLACK OR AFRICAN AMERICAN
<0> NO/NOT BLACK OR AFRICAN AMERICAN
MISSING/DK

Q43C

Was your family member Asian?
<1> YES/ASIAN
<0> NO/NOT ASIAN
MISSING/DK

Q43D

Was your family member Native Hawaiian or other Pacific Islander?
<1> YES/NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
<0> NO/NOT NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
MISSING/DK

Q43E

Was your family member American Indian or Alaska Native?
<1> YES/AMERICAN INDIAN OR ALASKA NATIVE
<0> NO/NOT AMERICAN INDIAN OR ALASKA NATIVE
MISSING/DK

December 2016

21

Q44_INTRO The next questions are about you.
Q44

What is your age?
READ ANSWER CHOICES ONLY IF NECESSARY
<1> 18 to 24
<2> 25 to 34
<3> 35 to 44
<4> 45 to 54
<5> 55 to 64
<6> 65 to 74
<7> 75 to 84
<8> 85 or older
MISSING/DK

Q45

INTERVIEWER ASK ONLY IF NEEDED: Are you male or female?
<1> MALE
<2> FEMALE
MISSING/DK

Q46

What is the highest grade or level of school that you have completed?
[OPTIONAL: Did you…]
READ ANSWER CHOICES ONLY IF NECESSARY
<1> Complete 8th grade or less,
<2> Complete some high school, but did not graduate,
<3> Graduate from high school or earn a GED,
<4> Complete some college or earn a 2-year degree,
<5> Graduate from a 4-year college, or
<6> Complete more than a 4-year college degree?
MISSING/DK
ACADEMIC TRAINING BEYOND A HIGH SCHOOL DIPLOMA THAT
DOES NOT LEAD TO A BACHELORS DEGREE SHOULD BE CODED AS 4.
IF THE RESPONDENT DESCRIBES NON-ACADEMIC TRAINING, SUCH
AS TRADE SCHOOL, PROBE TO FIND OUT IF SHE/HE HAS A HIGH
SCHOOL DIPLOMA AND CODE 2 OR 3, AS APPROPRIATE.

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December 2016

Q47

What language do you mainly speak at home? Please listen to all response choices
before you answer. Would you say that you mainly speak…
<1> English,
<2> Spanish,
<3> Chinese,
<4> Russian,
<5> Portuguese,
<6> Vietnamese,
<7> Polish,
<8> Korean, or
<9> Some other language?

[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO END]
[GO TO Q47A]

MISSING/DK

[GO TO END]

IF THE PATIENT REPLIES WITH MULTIPLE LANGUAGES, PROBE:
Would you say that you mainly speak [LANGUAGE A] or [LANGUAGE B]?
NOTE: IF THE PATIENT REPLIES THAT THEY SPEAK AMERICAN,
PLEASE CODE AS 1 – ENGLISH.
Q47A

What other language do you mainly speak at home?
NOTE: PLEASE DOCUMENT THE OTHER LANGUAGE AND MAINTAIN
IN YOUR INTERNAL RECORDS

END

Those are all the questions I have. [OPTIONAL: Should you like the number for
bereavement support at [HOSPICE NAME], I can provide that to you now.]
INTERVIEWER: PROVIDE CONTACT INFORMATION AS NEEDED.
Thank you for your time.

December 2016

23

PRA Disclosure Statement:
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 0938-1257. The time required to complete this information collection is estimated
to average 11 minutes for questions 1 – 40, the “About Your Family Member” questions and the “About
You” questions 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
21244-1850.

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December 2016