CMS-10500 OAS CAHPS (Web Survey Screenshots)

OMB No. 0938-1240
Expires 12/31/2021

WEB SURVEY INSTRUMENT WITH EXAMPLE LAYOUT
FOR THE OUTPATIENT AND AMBULATORY SURGERY CAHPS SURVEY
(OAS CAHPS®)

LANDING PAGE, IF GENERIC WEB SURVEY URL USED

lease input your survey access code.
Por favor ingrese su c6digo de acceso.

Take the Survey/ Tome pa rte de la encuesta

1

INTRO1 – IF NO DATE OF BIRTH MATCH, GO TO CONFIRM

OAS CAHPS® Survey
Patient Name:
Thank you for participating in the Outpatient and Ambulatory Surgery CAHPS Survey. To
ensure we are surveying the correct person, please enter your date of birth to access the
survey.
MM/DD/YYYY

Next>
Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.
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 09381240 with an expiration date of December 31, 2021. The time required to complete this information collection is
estimated to average 8 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.

2

OMB No. 0938-1240
Expires 12/31/2021

CONFIRM – If yes, continue. If no, go to Q_INELIG

OAS CAHPS® Survey
That date of birth does not match our records. To ensure we have the correct record,
please confirm if you had an outpatient surgery or procedure at [FACILITY NAME] on [DATE].

o Yes, I had an outpatient surgery or procedure at [FACILITY NAME]
o No, I did not have an outpatient surgery or procedure at [FACILITY NAME]

Next>
Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

INTRO2

OAS CAHPS® Survey
[FACILITY NAME] is participating in a survey about patients’ experiences with
outpatient surgeries and procedures. The results will be used to help [FACILITY NAME]
understand patient experiences in their facilities.
Your participation in this survey is completely voluntary and will not affect any health
care or benefits you receive. All information you provide is confidential and is
protected by the Privacy Act.

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

3

INTRO3

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

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q1

OAS CAHPS® Survey
BEFORE YOUR PROCEDURE
The first few questions are about getting ready for your procedure. Include any
information you received before and on the day of your procedure.
Before your procedure, did your doctor or anyone from the facility give you all the
information you needed about your procedure?

o Yes, definitely
o Yes, somewhat
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

4

OMB No. 0938-1240
Expires 12/31/2021

Q2

OAS CAHPS® Survey
BEFORE YOUR PROCEDURE
Before your procedure, did your doctor or anyone from the facility give you easy to
understand instructions about getting ready for your procedure?

o Yes, definitely
o Yes, somewhat
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q3

OAS CAHPS® Survey
ABOUT THE FACILITY AND STAFF
The next questions ask about the day of your procedure.
Did the check-in process run smoothly?

o Yes, definitely
o Yes, somewhat
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.
5

Q4

OAS CAHPS® Survey
ABOUT THE FACILITY AND STAFF
Was the facility clean?

o Yes, definitely
o Yes, somewhat
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q5

OAS CAHPS® Survey
ABOUT THE FACILITY AND STAFF
Were the clerks and receptionists as helpful as you thought they should be?

o Yes, definitely
o Yes, somewhat
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

6

OMB No. 0938-1240
Expires 12/31/2021

Q6

OAS CAHPS® Survey
ABOUT THE FACILITY AND STAFF

Did the clerks and receptionists treat you with courtesy and respect?

o Yes, definitely
o Yes, somewhat
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q7

OAS CAHPS® Survey
ABOUT THE FACILITY AND STAFF
Did the doctors and nurses treat you with courtesy and respect?

o Yes, definitely
o Yes, somewhat
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

7

Q8

OAS CAHPS® Survey
ABOUT THE FACILITY AND STAFF
Did the doctors and nurses make sure you were as comfortable as possible?

o Yes, definitely
o Yes, somewhat
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q9

OAS CAHPS® Survey
COMMUNICATIONS ABOUT YOUR PROCEDURE
As a reminder, please include any information you received before and on the day of
the procedure.
Did the doctors and nurses explain your procedure in a way that was easy to
understand?

o Yes, definitely
o Yes, somewhat
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.
8

OMB No. 0938-1240
Expires 12/31/2021

Q10

LOGIC AFTER: IF Q10 = NO OR BLANK, THEN GO TO Q13

OAS CAHPS® Survey
COMMUNICATIONS ABOUT YOUR PROCEDURE
Anesthesia is something that would make you feel sleepy or go to sleep during your
procedure. Were you given anesthesia?

o Yes
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q11

OAS CAHPS® Survey
COMMUNICATIONS ABOUT YOUR PROCEDURE
Did your doctor or anyone from the facility explain the process of giving anesthesia in
a way that was easy to understand?

o Yes, definitely
o Yes, somewhat
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.
9

Q12

OAS CAHPS® Survey
COMMUNICATIONS ABOUT YOUR PROCEDURE
Did your doctor or anyone from the facility explain the possible side effects of the
anesthesia in a way that was easy to understand?

o Yes, definitely
o Yes, somewhat
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q13

OAS CAHPS® Survey
COMMUNICATIONS ABOUT YOUR PROCEDURE
Discharge instructions include things like symptoms you should watch for after your
procedure, instructions about medicines, and home care. Before you left the facility,
did you receive written discharge instructions?

o Yes
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

10

OMB No. 0938-1240
Expires 12/31/2021

Q14

OAS CAHPS® Survey
YOUR RECOVERY
Did your doctor or anyone from the facility prepare you for what to expect during
your recovery?

o Yes, definitely
o Yes, somewhat
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

11

Q15

OAS CAHPS® Survey
YOUR RECOVERY
The next questions are about possible outcomes you could have during recovery.
Some procedures do not require that you get this information. Please answer based
on what you remember.
Some ways to control pain include prescription medicine, over-the-counter pain
relievers or ice packs. Did your doctor or anyone from the facility give you
information about what to do if you had pain as a result of your procedure?

o Yes
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q16

OAS CAHPS® Survey
YOUR RECOVERY
At any time after leaving the facility, did you have pain as a result of your procedure?

o Yes
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

12

OMB No. 0938-1240
Expires 12/31/2021

Q17

OAS CAHPS® Survey
YOUR RECOVERY
Before you left the facility, did your doctor or anyone from the facility give you
information about what to do if you had nausea or vomiting?

o Yes
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q18

OAS CAHPS® Survey
YOUR RECOVERY
At any time after leaving the facility, did you have nausea or vomiting as a result of
either your procedure or the anesthesia?

o Yes
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.
13

Q19

OAS CAHPS® Survey
YOUR RECOVERY
Before you left the facility, did your doctor or anyone from the facility give you
information about what to do if you had bleeding as a result of your procedure?

o Yes
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q20

OAS CAHPS® Survey
YOUR RECOVERY
At any time after leaving the facility, did you have bleeding as a result of your
procedure?

o Yes
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

14

OMB No. 0938-1240
Expires 12/31/2021

Q21

OAS CAHPS® Survey
YOUR RECOVERY
Possible signs of infection include fever, swelling, heat, drainage or redness. Before
you left the facility, did your doctor or anyone from the facility give you information
about what to do if you had possible signs of infection?

o Yes
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q22

OAS CAHPS® Survey
YOUR RECOVERY
At any time after leaving the facility, did you have any signs of infection?

o Yes
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

15

Q23

OAS CAHPS® Survey
YOUR OVERALL EXPERIENCE
Using any number from 0 to 10, where 0 is the worst facility possible and 10 is the
best facility possible, what number would you use to rate this facility?
Worst
Facility

Best
Facility

0

1

2

3

4

5

6

7

8

9

10

0

0

0

0

0

0

0

0

0

0

0

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q24

OAS CAHPS® Survey
YOUR OVERALL EXPERIENCE

Would you recommend this facility to your friends and family?

o Definitely no
o Probably no
o Probably yes
o Definitely yes

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.
16

OMB No. 0938-1240
Expires 12/31/2021

Q25

OAS CAHPS® Survey
ABOUT YOU

In general, how would you rate your overall health?

o Excellent
o Very good
o Good
o Fair
o Poor

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q26

OAS CAHPS® Survey
ABOUT YOU

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

o Excellent
o Very good
o Good
o Fair
o Poor

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

17

Q27

OAS CAHPS® Survey
ABOUT YOU
What is the highest grade or level of school that you have completed?

o 8th grade or less
o Some high school, but did not graduate
o High school graduate or GED
o Some college or 2-year degree
o 4-year college graduate
o More than 4-year college degree

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q28

LOGIC AFTER: IF Q28 = NO OR BLANK, THEN GO TO Q30

OAS CAHPS® Survey
ABOUT YOU

Are you of Hispanic, Latino, or Spanish origin?

o Yes, Hispanic, Latino, or Spanish
o No, not Hispanic, Latino, or Spanish

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

18

OMB No. 0938-1240
Expires 12/31/2021

Q29

OAS CAHPS® Survey
ABOUT YOU
Which group best describes you?

o
o
o
o

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q30

OAS CAHPS® Survey
ABOUT YOU
What is your race? You may select one or more categories.







Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

19

Q30a

PRELOGIC: IF Q30 = ASIAN, ASK Q30a; ELSE, GO TO Q31

OAS CAHPS® Survey
ABOUT YOU
Which groups best describe you? You may select one or more categories.








Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
None of the above

B

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q30b PRELOGIC: IF Q30 = HAWAIIAN, ASK Q30b ELSE, GO TO Q31.

OAS CAHPS® Survey
ABOUT YOU
Which groups best describe you? You may select one or more categories.






Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

20

OMB No. 0938-1240
Expires 12/31/2021

Q31

OAS CAHPS® Survey
ABOUT YOU

How well do you speak English?

o
o
o
o

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

21

Q32

OAS CAHPS® Survey
ABOUT YOU

What language do you mainly speak at home?

o English
o Spanish
o Chinese
o Russian
o Vietnamese
o Portuguese
o German
o Some other language

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q33

LOGIC AFTER: IF Q33 = NO OR BLANK, THEN GO TO Q_END

OAS CAHPS® Survey
ABOUT YOU

Did someone help you complete this survey?

o Yes
o No

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.
22

OMB No. 0938-1240
Expires 12/31/2021

Q34

OAS CAHPS® Survey
ABOUT YOU

How did that person help you? Check all that apply.







Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

Q_END

OAS CAHPS® Survey
You have completed the OAS CAHPS Survey. Thank you for your time.
Please click the “Submit” button.

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

23

Q_INELIG

PRELOGIC: DOB DOES NOT MATCH WHAT WE HAVE ON FILE AND
CONFIRM=NO

OAS CAHPS® Survey
Thank you for your time. It looks like you are not the person we need to compete this
survey.

Questions? Contact the OAS CAHPS Survey Coordination Team at [VENDOR EMAIL ADDRESS] or call 1-8XXXXX-XXXX.

24