CMS-10105 Medicare In-Center Hemodialysis Survey (English)

OMB #: 0938-0926
Expiration Date: TBD

Medicare In-Center Hemodialysis
Survey

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 0938-0926. The time required to complete this
information collection is estimated to average 16 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 any comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA
Reports Clearance Officer, 7500 Security Boulevard, Mail Stop C1-25-05, Baltimore, Maryland
21244-1850.

Survey Instructions
This survey is about your experiences with dialysis care at [SAMPLE FACILITY
NAME].

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:

1.

Where do you get your dialysis
treatments?
1

2

2.

3.

At home or at a skilled nursing
home where I live If At
home or at a skilled nursing
home where I live, Go to
Question 45
At the dialysis center

In the last 3 months, how often
did your kidney doctors listen
carefully to you?
1

Never

1

Never

1

Never

1

Never

How long have you been getting
dialysis at [SAMPLE FACILITY
NAME]?
1

2

Less than 3 months If Less
than 3 months, Go to
Question 45
At least 3 months but less
than 1 year

YOUR KIDNEY DOCTORS
Your kidney doctors are the doctor or
doctors most involved in your
dialysis care now. This includes
kidney doctors that you see inside
and outside the center.

1

7.

In the last 3 months, how often
did you feel your kidney doctors
really cared about you as a
person?

For the next questions, dialysis
center staff does not include doctors.
Dialysis center staff means nurses,
technicians, dietitians, and social
workers at this dialysis center.

Never

1

10. In the last 3 months, how often
did the dialysis center staff
listen carefully to you?

0

1

1

Never

1

Never

1

Never

1

Never

0 Worst kidney doctors
possible

Yes

2

14. In the last 3 months, how often
did you feel the dialysis center
staff really cared about you as a
person?
1

1

Never

Never

1

Yes

1

Yes

1

1

Yes

1

Graft

4

I don’t know If Don’t
Know, Go to Question 22

21. In the last 3 months, how often
did dialysis center staff insert
your needles with as little pain
as possible?

Yes

3

1

Never

1

Never

23. In the last 3 months, did any
problems occur during your
dialysis?
1

Yes

1

Never

1

Yes

1

Yes

1

Yes

1

Yes

24. In the last 3 months, how often
was the dialysis center staff able
to manage problems during your
dialysis?
1

1

Never

Never

26. In the last 3 months, did dialysis
center staff talk to you about
what you should eat and drink?
1

Yes

4

32. Using any number from 0 to 10,
where 0 is the worst dialysis
center staff possible and 10 is
the best dialysis center staff
possible, what number would
you use to rate your dialysis
center staff?
0

0

0 Worst dialysis center staff
possible

The next few questions ask about
your care in the last 12 months. As
you answer these questions, think
only about your experience at
[SAMPLE FACILITY NAME], even if
you have not been receiving care
there for the entire 12 months.

33. In the last 3 months, when you
arrived on time, how often did
you get put on the dialysis
machine within 15 minutes of
your appointment or shift time?
1

1

0 Worst dialysis center
possible

Never

36. You can treat kidney disease
with dialysis at a center, a
kidney transplant, or with
dialysis at home. In the last 12
months, did your kidney doctors
or dialysis center staff talk to
you as much as you wanted
about which treatment is right
for you?

Never

1

5

Yes

37. Are you eligible for a kidney
transplant?
1
2

42. In the last 12 months, did you
ever talk to someone on the
dialysis center staff about this?

Yes If Yes, Go to
Question 39
No

1

43. In the last 12 months, how often
were you satisfied with the way
they handled these problems?

38. In the last 12 months, has a
doctor or dialysis center staff
explained to you why you are
not eligible for a kidney
transplant?
1

1

Yes

1

Never

1

Yes

Yes

Yes

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

Yes

1

Yes

6

Excellent

46. In general, how would you rate
your overall mental or emotional
health?
1

1

Excellent

Yes

1

Yes

1

Yes

1

Yes

1

Yes

1

Yes

1

No formal education

Yes

1

1

1

Yes

Yes

7

57. What language do you mainly
speak at home?
English

1

1

Yes

61. Who helped you complete this
survey?
1

A family member

1

Read the questions to me

No, not Spanish/Hispanic/
Latino
Yes, Puerto Rican

1
2

59. What is your race? (One or more
categories may be selected.)
1

White

VENDOR’S NAME
STREET ADDRESS 1
STREET ADDRESS 2
CITY, STATE, ZIP

8