CMS-10537 Hospice Experience of Care Survey -

CAHPS® Hospice Survey
Please answer the survey questions about the care the patient received from this
hospice:

[NAME OF HOSPICE]

All of the questions in this survey will ask about the experiences with this
hospice.

If you want to know more about this survey, please call [TOLL FREE NUMBER]. All
calls to that number are free.

OMB#0938-1257
Expires December 31, 2023

December 2022

1

CAHPS® Hospice Survey
SURVEY INSTRUCTIONS
♦

Please give this survey to the person in your household who knows the most about
the hospice care received by the person listed on the survey cover letter.

♦

Use a dark colored pen to fill out the survey.

♦

Place an X directly inside the square indicating a response, like in the sample below.
Yes
No

♦

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 Question 1
No
_____________________________________________________________________

THE HOSPICE PATIENT
1. How are you related to the person
listed on the survey cover letter?


2
3

My spouse or partner


5
6
7
8
9

My grandparent

1

4

2

My parent
My mother-in-law or father-inlaw
My aunt or uncle
My sister or brother
My child
My friend

2. For this survey, the phrase "family
member" refers to the person
listed on the survey cover letter.
In what locations did your family
member receive care from this
hospice? Please choose one or
more.


2
3
4
5
6
1

Home
Assisted living facility
Nursing home
Hospital
Hospice facility/hospice house
Other (please print):

Other (please print):

December 2022

YOUR ROLE
3. While your family member was in
hospice care, how often did you
take part in or oversee care for
him or her?



1


3
4
2

Never  If Never, go to
Question 41
Sometimes
Usually
Always

YOUR FAMILY MEMBER’S
HOSPICE CARE
As you answer the rest of the
questions in this survey, please think
only about your family member's
experience with the hospice named
on the survey cover.
4. 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?




1
2

Yes
No  If No, go to Question 6

5. How often did you get the help
you needed from the hospice
team during evenings, weekends,
or holidays?



3
4
1
2

Never
Sometimes
Usually
Always

December 2022

6. 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?



3
4
1
2

Never
Sometimes
Usually
Always

7. 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?


2
3
4
1

Never
Sometimes
Usually
Always

8. While your family member was in
hospice care, how often did the
hospice team explain things in a
way that was easy to understand?



3
4
1
2

Never
Sometimes
Usually
Always

9. While your family member was in
hospice care, how often did the
hospice team keep you informed
about your family member’s
condition?



3
4
1
2

Never
Sometimes
Usually
Always

3

10. 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?



3
4
1
2

Never
Sometimes
Usually
Always

11. While your family member was in
hospice care, how often did the
hospice team treat your family
member with dignity and respect?


2
3
4
1

Never
Sometimes
Usually
Always

12. While your family member was in
hospice care, how often did you
feel that the hospice team really
cared about your family member?



3
4
1
2

Never
Sometimes
Usually
Always

13. 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?


2
1

4

Yes
No  If No, go to Question 15

14. How often did the hospice team
listen carefully to you when you
talked with them about problems
with your family member’s
hospice care?



3
4
1
2

Never
Sometimes
Usually
Always

15. While your family member was in
hospice care, did he or she have
any pain?




1
2

Yes
No  If No, go to Question 17

16. Did your family member get as
much help with pain as he or she
needed?


2
3
1

Yes, definitely
Yes, somewhat
No

17. While your family member was in
hospice care, did he or she
receive any pain medicine?




1
2

Yes
No  If No, go to Question 21

18. 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?


2
3
1

Yes, definitely
Yes, somewhat
No

December 2022

19. Did the hospice team give you the
training you needed about what
side effects to watch for from pain
medicine?


2
3
1

Yes, definitely
Yes, somewhat
No

20. Did the hospice team give you the
training you needed about if and
when to give more pain medicine
to your family member?


2
3
4
1

Yes, definitely
Yes, somewhat
No
I did not need to give pain
medicine to my family member

21. While your family member was in
hospice care, did your family
member ever have trouble
breathing or receive treatment for
trouble breathing?




1
2

Yes
No  If No, go to Question 24

22. How often did your family member
get the help he or she needed for
trouble breathing?


2
3
4
1

Never
Sometimes
Usually
Always

December 2022

23. Did the hospice team give you the
training you needed about how to
help your family member if he or
she had trouble breathing?


2
3
4
1

Yes, definitely
Yes, somewhat
No
I did not need to help my family
member with trouble breathing

24. While your family member was in
hospice care, did your family
member ever have trouble with
constipation?


2
1

Yes
No  If No, go to Question 26

25. How often did your family member
get the help he or she needed for
trouble with constipation?



3
4
1
2

Never
Sometimes
Usually
Always

26. While your family member was in
hospice care, did he or she show
any feelings of anxiety or
sadness?




1
2

Yes
No  If No, go to Question 28

5

27. How often did your family member
get the help he or she needed
from the hospice team for feelings
of anxiety or sadness?


2
3
4
1

Never
Sometimes
Usually
Always

28. While your family member was in
hospice care, did he or she ever
become restless or agitated?


2
1

Yes
No  If No, go to Question 30

29. Did the hospice team give you the
training you needed about what to
do if your family member became
restless or agitated?


2
3
1

Yes, definitely
Yes, somewhat
No

30. 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?



3
4
1
2

6

31. Did the hospice team give you as
much information as you wanted
about what to expect while your
family member was dying?


2
3
1

Yes, definitely
Yes, somewhat
No

HOSPICE CARE RECEIVED IN A
NURSING HOME
32. 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?


2
1

Yes
No  If No, go to Question 35

33. 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?


2
3
4
1

Never
Sometimes
Usually
Always

Yes, definitely
Yes, somewhat
No
I did not need to move my
family member

December 2022

34. 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?



3
4
1
2

Never
Sometimes
Usually
Always

YOUR OWN EXPERIENCE WITH
HOSPICE
35. While your family member was in
hospice care, how often did the
hospice team listen carefully to
you?



3
4
1
2

37. While your family member was in
hospice care, how much
emotional support did you get
from the hospice team?


2
3
1

Too little
Right amount
Too much

38. In the weeks after your family
member died, how much
emotional support did you get
from the hospice team?


2
3
1

Too little
Right amount
Too much

Never
Sometimes
Usually
Always

36. 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?



3
1
2

Too little
Right amount
Too much

December 2022

7

OVERALL RATING OF HOSPICE
CARE
39. Please answer the following
questions about your family
member’s care from the hospice
named on the survey cover. 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?

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

Worst hospice care possible



3
4
2

8

41. What is the highest grade or level
of school that your family member
completed?


2
1


4
5
6
3



7


2
3



4
5

Best hospice care possible

Definitely no
Probably no
Probably yes
Definitely yes

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
Don’t know

42. Was your family member of
Hispanic, Latino, or Spanish
origin or descent?
1

40. Would you recommend this
hospice to your friends and
family?
1

ABOUT YOUR FAMILY MEMBER

No, not Spanish/Hispanic/Latino
Yes, Cuban
Yes, Mexican, Mexican
American, Chicano/a
Yes, Puerto Rican
Yes, Other Spanish/Hispanic/
Latino

43. What was your family member’s
race? Please choose one or more.



1



4
2
3



5

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

December 2022

ABOUT YOU
44. What is your age?


2
3
4
5
6
7
8
1

18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 to 84
85 or older


2
1


4
5
6
3

45. Are you male or female?




1
2

Male
Female

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

47. What language do you mainly
speak at home?


2
3
4
5
6
7
8
9
1

English
Spanish
Chinese
Russian
Portuguese
Vietnamese
Polish
Korean
Some other language (please
print):

THANK YOU
Please return the completed survey in the postage-paid envelope.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]

December 2022

9

10

December 2022

CAHPS® Hospice Survey
Please answer the survey questions about the care the patient received from this
hospice:

[NAME OF HOSPICE]

All of the questions in this survey will ask about the experiences with this
hospice.

If you want to know more about this survey, please call [TOLL FREE NUMBER]. All
calls to that number are free.

OMB#0938-1257
Expires December 31, 2023

December 2022

11

CAHPS® Hospice Survey
SURVEY INSTRUCTIONS
♦

Please give this survey to the person in your household who knows the most about
the hospice care received by the person listed on the survey cover letter.

♦

Use a dark colored pen to fill out the survey.

♦

Answer all the questions by completely filling in the circle to the left of your answer.

♦

0

Yes
No

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:

0

Yes  If Yes, Go to Question 1

No
_____________________________________________________________________

THE HOSPICE PATIENT
1. How are you related to the person
listed on the survey cover letter?

0
20
30

My spouse or partner

0
50
60
70
80
90

My grandparent

1

4

12

My parent
My mother-in-law or father-inlaw
My aunt or uncle
My sister or brother
My child
My friend

2. For this survey, the phrase "family
member" refers to the person
listed on the survey cover letter.
In what locations did your family
member receive care from this
hospice? Please choose one or
more.

0
20
30
40
50
60
1

Home
Assisted living facility
Nursing home
Hospital
Hospice facility/hospice house
Other (please print):

Other (please print):

December 2022

YOUR ROLE
3. While your family member was in
hospice care, how often did you
take part in or oversee care for
him or her?

0

1

0
30
40
2

Never  If Never, go to
Question 41
Sometimes
Usually
Always

YOUR FAMILY MEMBER’S
HOSPICE CARE
As you answer the rest of the
questions in this survey, please think
only about your family member's
experience with the hospice named
on the survey cover.
4. 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?

0
20
1

Yes
No  If No, go to Question 6

5. How often did you get the help
you needed from the hospice
team during evenings, weekends,
or holidays?

0
0
30
40
1

Never

2

Sometimes
Always

6. 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?

0
20
30
40
1

Never
Sometimes
Usually
Always

7. 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?

0
20
30
40
1

Never
Sometimes
Usually
Always

8. While your family member was in
hospice care, how often did the
hospice team explain things in a
way that was easy to understand?

0
20
30
40
1

December 2022

Usually

Never
Sometimes
Usually
Always

13

9. While your family member was in
hospice care, how often did the
hospice team keep you informed
about your family member’s
condition?

0
20
30
40
1

Never
Sometimes
Usually
Always

10. 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?

0
20
30
40
1

Never
Sometimes
Usually
Always

11. While your family member was in
hospice care, how often did the
hospice team treat your family
member with dignity and respect?

0
0
30
40

0
20
1

Yes
No  If No, go to Question 15

14. How often did the hospice team
listen carefully to you when you
talked with them about problems
with your family member’s
hospice care?

0
20
30
40
1

Never
Sometimes
Usually
Always

15. While your family member was in
hospice care, did he or she have
any pain?

0
20
1

Yes
No  If No, go to Question 17

16. Did your family member get as
much help with pain as he or she
needed?

1

Never

2

Sometimes

1

Yes, definitely

Usually

2

Yes, somewhat

Always

12. While your family member was in
hospice care, how often did you
feel that the hospice team really
cared about your family member?

0
20
30
40
1

14

13. 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?

Never
Sometimes

0
0
30

No

17. While your family member was in
hospice care, did he or she
receive any pain medicine?

0
0

1

Yes

2

No  If No, go to Question 21

Usually
Always

December 2022

18. 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?

0
20
30
1

Yes, definitely
Yes, somewhat
No

19. Did the hospice team give you the
training you needed about what
side effects to watch for from pain
medicine?

0
20
30
1

Yes, definitely
Yes, somewhat
No

20. Did the hospice team give you the
training you needed about if and
when to give more pain medicine
to your family member?

0
0
30
40
1

Yes, definitely

2

Yes, somewhat
No
I did not need to give pain
medicine to my family member

21. While your family member was in
hospice care, did your family
member ever have trouble
breathing or receive treatment for
trouble breathing?

0
0

1

Yes

2

No  If No, go to Question 24

22. How often did your family member
get the help he or she needed for
trouble breathing?

0
20
30
40
1

Sometimes
Usually
Always

23. Did the hospice team give you the
training you needed about how to
help your family member if he or
she had trouble breathing?

0
20
30
40
1

Yes, definitely
Yes, somewhat
No
I did not need to help my family
member with trouble breathing

24. While your family member was in
hospice care, did your family
member ever have trouble with
constipation?

0
0

1

Yes

2

No  If No, go to Question 26

25. How often did your family member
get the help he or she needed for
trouble with constipation?

0
20
30
40
1

Never
Sometimes
Usually
Always

26. While your family member was in
hospice care, did he or she show
any feelings of anxiety or
sadness?

0
20
1

December 2022

Never

Yes
No  If No, go to Question 28
15

27. How often did your family member
get the help he or she needed
from the hospice team for feelings
of anxiety or sadness?

0
20
30
40
1

0
20

1

Yes, definitely

Sometimes

2

Yes, somewhat

Usually
Always

Yes
No  If No, go to Question 30

29. Did the hospice team give you the
training you needed about what to
do if your family member became
restless or agitated?

0
20
30
1

Yes, definitely
Yes, somewhat
No

30. 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?

0
20
30
40
1

16

0
0
30

Never

28. While your family member was in
hospice care, did he or she ever
become restless or agitated?
1

31. Did the hospice team give you as
much information as you wanted
about what to expect while your
family member was dying?

Yes, definitely
Yes, somewhat
No
I did not need to move my
family member

No

HOSPICE CARE RECEIVED IN A
NURSING HOME
32. 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?

0
0

1

Yes

2

No  If No, go to Question 35

33. 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?

0
0
30
40
1

Never

2

Sometimes
Usually
Always

34. 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?

0
0
30
40
1

Never

2

Sometimes
Usually
Always

December 2022

YOUR OWN EXPERIENCE WITH
HOSPICE
35. While your family member was in
hospice care, how often did the
hospice team listen carefully to
you?

0
20
30
40
1

Never
Sometimes
Usually
Always

36. 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?

0
20
30
1

Too little
Right amount
Too much

37. While your family member was in
hospice care, how much
emotional support did you get
from the hospice team?

0
20
30
1

Too little
Right amount
Too much

38. In the weeks after your family
member died, how much
emotional support did you get
from the hospice team?

0
0
30
1

Too little

2

Right amount

OVERALL RATING OF
HOSPICE CARE
39. Please answer the following
questions about your family
member’s care from the hospice
named on the survey cover. 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?

0
0
20
30
40
50
60
70
80
90
100
0

0 Worst hospice care possible

1

1
2
3
4
5
6
7
8
9
10 Best hospice care possible

40. Would you recommend this
hospice to your friends and
family?

0
0
30
40
1

Definitely no

2

Probably no
Probably yes
Definitely yes

Too much

December 2022

17

ABOUT YOUR FAMILY MEMBER
41. What is the highest grade or level
of school that your family member
completed?

0
20
1

0
0
50
60
3
4

0

7

8th grade or less
Some high school but did not
graduate
High school graduate or GED
Some college or 2-year degree

0
20
30
0
0

4
5

18

0

1

0
0
40
2
3

0

5

4-year college graduate
More than 4-year college
degree
Don’t know

42. Was your family member of
Hispanic, Latino, or Spanish
origin or descent?
1

43. What was your family member’s
race? Please choose one or more.

No, not Spanish/Hispanic/Latino
Yes, Cuban
Yes, Mexican, Mexican
American, Chicano/a
Yes, Puerto Rican
Yes, Other Spanish/Hispanic/
Latino

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

ABOUT YOU
44. What is your age?

0
20
30
40
50
60
70
80
1

18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 to 84
85 or older

45. Are you male or female?

0
0

1

Male

2

Female

December 2022

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

0
20
1

0
40
50
60
3

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

47. What language do you mainly
speak at home?

0
0
30
40
50
60
70
80
90
1

English

2

Spanish
Chinese
Russian
Portuguese
Vietnamese
Polish
Korean
Some other language (please
print):

THANK YOU
Please return the completed survey in the postage-paid envelope.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]

December 2022

19

20

December 2022

CAHPS® Hospice Survey
Please answer the survey questions about the care the patient received from this
hospice:

[NAME OF HOSPICE]

All of the questions in this survey will ask about the experiences with this
hospice.

If you want to know more about this survey, please call [TOLL FREE NUMBER]. All
calls to that number are free.

OMB#0938-1257
Expires December 31, 2023

December 2022

21

CAHPS® Hospice Survey
SURVEY INSTRUCTIONS
♦

Please give this survey to the person in your household who knows the most about
the hospice care received by the person listed on the survey cover letter.

♦

Use a dark colored pen to fill out the survey.

♦

Answer all the questions by completely filling in the circle to the left of your answer.
 Yes



♦

No

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 Question 1

No
_____________________________________________________________________

THE HOSPICE PATIENT
1. How are you related to the person
listed on the survey cover letter?

O
2O
3O

My spouse or partner

O
5O
6O
7O
8O
9O

My grandparent

1

4

My parent
My mother-in-law or father-inlaw
My aunt or uncle
My sister or brother
My child
My friend

2. For this survey, the phrase
"family member" refers to the
person listed on the survey cover
letter. In what locations did your
family member receive care from
this hospice? Please choose one
or more.

O
2O
3O
4O
5O
6O
1

Home
Assisted living facility
Nursing home
Hospital
Hospice facility/hospice house
Other (please print):

Other (please print):
_________________________

22

December 2022

YOUR ROLE
3. While your family member was in
hospice care, how often did you
take part in or oversee care for
him or her?

O

1

O
3O
4O
2

Never  If Never, go to
Question 41
Sometimes
Usually
Always

YOUR FAMILY MEMBER’S
HOSPICE CARE
As you answer the rest of the
questions in this survey, please think
only about your family member's
experience with the hospice named
on the survey cover.
4. 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?

O
2O
1

Yes
No  If No, go to Question 6

5. How often did you get the help
you needed from the hospice
team during evenings, weekends,
or holidays?

O
O
3O
4O
1

Never

2

Sometimes
Always

6. 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?

O
2O
3O
4O
1

Never
Sometimes
Usually
Always

7. 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?

O
2O
3O
4O
1

Never
Sometimes
Usually
Always

8. While your family member was in
hospice care, how often did the
hospice team explain things in a
way that was easy to understand?

O
2O
3O
4O
1

December 2022

Usually

Never
Sometimes
Usually
Always

23

9.

While your family member was in
hospice care, how often did the
hospice team keep you informed
about your family member’s
condition?

O
2O
3O
4O
1

Never
Sometimes
Usually
Always

10. 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?

O
2O
3O
4O
1

Never
Sometimes
Usually
Always

11. While your family member was in
hospice care, how often did the
hospice team treat your family
member with dignity and respect?

O
O
3O
4O

O
2O
1

Yes
No  If No, go to Question 15

14. How often did the hospice team
listen carefully to you when you
talked with them about problems
with your family member’s
hospice care?

O
2O
3O
4O
1

Never
Sometimes
Usually
Always

15. While your family member was in
hospice care, did he or she have
any pain?

O
2O
1

Yes
No  If No, go to Question 17

16. Did your family member get as
much help with pain as he or she
needed?

1

Never

2

Sometimes

1

Yes, definitely

Usually

2

Yes, somewhat

Always

12. While your family member was in
hospice care, how often did you
feel that the hospice team really
cared about your family member?

O
2O
3O
4O
1

24

13. 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?

Never
Sometimes

O
O
3O

No

17. While your family member was in
hospice care, did he or she
receive any pain medicine?

O
O

1

Yes

2

No  If No, go to Question 21

Usually
Always

December 2022

18. 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?

O
2O
3O
1

Yes, definitely
Yes, somewhat
No

19. Did the hospice team give you the
training you needed about what
side effects to watch for from pain
medicine?

O
2O
3O
1

Yes, definitely
Yes, somewhat
No

20. Did the hospice team give you the
training you needed about if and
when to give more pain medicine
to your family member?

O
O
3O
4O
1

Yes, definitely

2

Yes, somewhat
No
I did not need to give pain
medicine to my family member

21. While your family member was in
hospice care, did your family
member ever have trouble
breathing or receive treatment for
trouble breathing?

O
O

1

Yes

2

No  If No, go to Question 24

22. How often did your family member
get the help he or she needed for
trouble breathing?

O
2O
3O
4O
1

Sometimes
Usually
Always

23. Did the hospice team give you the
training you needed about how to
help your family member if he or
she had trouble breathing?

O
2O
3O
4O
1

Yes, definitely
Yes, somewhat
No
I did not need to help my family
member with trouble breathing

24. While your family member was in
hospice care, did your family
member ever have trouble with
constipation?

O
O

1

Yes

2

No  If No, go to Question 26

25. How often did your family member
get the help he or she needed for
trouble with constipation?

O
2O
3O
4O
1

Never
Sometimes
Usually
Always

26. While your family member was in
hospice care, did he or she show
any feelings of anxiety or
sadness?

O
2O
1

December 2022

Never

Yes
No  If No, go to Question 28
25

27. How often did your family member
get the help he or she needed
from the hospice team for feelings
of anxiety or sadness?

O
2O
3O
4O
1

O
2O

1

Yes, definitely

Sometimes

2

Yes, somewhat

Usually
Always

Yes
No  If No, go to Question 30

29. Did the hospice team give you the
training you needed about what to
do if your family member became
restless or agitated?

O
2O
3O
1

Yes, definitely
Yes, somewhat
No

30. 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?

O
2O
3O
4O
1

26

O
O
3O

Never

28. While your family member was in
hospice care, did he or she ever
become restless or agitated?
1

31. Did the hospice team give you as
much information as you wanted
about what to expect while your
family member was dying?

Yes, definitely
Yes, somewhat
No
I did not need to move my
family member

No

HOSPICE CARE RECEIVED IN A
NURSING HOME
32. 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?

O
O

1

Yes

2

No  If No, go to Question 35

33. 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?

O
O
3O
4O
1

Never

2

Sometimes
Usually
Always

34. 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?

O
O
3O
4O
1

Never

2

Sometimes
Usually
Always

December 2022

YOUR OWN EXPERIENCE WITH
HOSPICE
35. While your family member was in
hospice care, how often did the
hospice team listen carefully to
you?

O
2O
3O
4O
1

Never
Sometimes
Usually
Always

36. 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?

O
2O
3O
1

Too little
Right amount
Too much

37. While your family member was in
hospice care, how much
emotional support did you get
from the hospice team?

O
2O
3O
1

Too little
Right amount
Too much

38. In the weeks after your family
member died, how much
emotional support did you get
from the hospice team?

O
O
3O
1

Too little

2

Right amount

OVERALL RATING OF
HOSPICE CARE
39. Please answer the following
questions about your family
member’s care from the hospice
named on the survey cover. 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?

O
O
2O
3O
4O
5O
6O
7O
8O
9O
10O
0

0 Worst hospice care possible

1

1
2
3
4
5
6
7
8
9
10 Best hospice care possible

40. Would you recommend this
hospice to your friends and
family?

O
O
3O
4O
1

Definitely no

2

Probably no
Probably yes
Definitely yes

Too much

December 2022

27

ABOUT YOUR FAMILY MEMBER
41. What is the highest grade or level
of school that your family member
completed?

O
2O
1

O
4O
5O
6O
3

O

7

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
Don’t know

42. Was your family member of
Hispanic, Latino, or Spanish
origin or descent?

O
2O
3O
1

O
O

4
5

ABOUT YOU
44. What is your age?

O
2O
3O
4O
5O
6O
7O
8O
1

18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 to 84
85 or older

45. Are you male or female?

O
2O
1

Male
Female

No, not Spanish/Hispanic/Latino
Yes, Cuban
Yes, Mexican, Mexican
American, Chicano/a
Yes, Puerto Rican
Yes, Other Spanish/Hispanic/
Latino

43. What was your family member’s
race? Please choose one or more.

O

1

O
3O
4O
2

O

5

28

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

December 2022

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

O
2O
1

O
4O
5O
6O
3

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

47. What language do you mainly
speak at home?

O
O
3O
4O
5O
6O
7O
8O
9O
1

English

2

Spanish
Chinese
Russian
Portuguese
Vietnamese
Polish
Korean
Some other language (please
print):
_______________________

THANK YOU
Please return the completed survey in the postage-paid envelope.
[NAME OF SURVEY VENDOR]
[RETURN ADDRESS OF SURVEY VENDOR]

December 2022

29

30

December 2022

Sample Initial Cover Letter for the CAHPS Hospice Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
Dear [SAMPLED CAREGIVER NAME]:
[HOSPICE NAME] is conducting a survey about the hospice services that patients and their
families receive. You were selected for this survey because you were identified as the caregiver of
[DECEDENT NAME]. We realize this may be a difficult time for you, but we hope that you will
help us learn about the quality of care that you and your family member or friend received from
the hospice.
Questions [NOTE THE QUESTION NUMBERS] in the enclosed survey are part of a national
initiative sponsored by the United States Department of Health and Human Services (HHS) to
measure the quality of care in hospices. The Centers for Medicare & Medicaid Services (CMS),
which is part of HHS, is conducting this survey to improve hospice care. CMS pays for most of
the hospice care in the U.S. It is CMS’ responsibility to ensure that hospice patients and their
family members and friends get high quality care. One of the ways they can fulfill this
responsibility is to find out directly from you about the hospice care your family member or friend
received. Your participation is voluntary and will not affect any health care or benefits you receive.
We hope that you will take the time to complete the survey. After you have completed the survey,
please return it in the pre-paid envelope. Your answers may be shared with the hospice for purposes
of quality improvement. [OPTIONAL: 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.]
If you have any questions about the enclosed survey, please call the toll-free number 1-800-xxxxxxx. Thank you for helping to improve hospice care for all consumers.
Sincerely,
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]

December 2022

31

32

December 2022

Sample Follow-up Cover Letter for the CAHPS Hospice
Survey
[HOSPICE OR VENDOR LETTERHEAD]
[SAMPLED CAREGIVER NAME]
[ADDRESS]
[CITY, STATE ZIP]
Dear [SAMPLED CAREGIVER NAME]:
Our records show that you were recently a caregiver for [DECEDENT NAME] at [NAME OF
HOSPICE]. Approximately three weeks ago, we sent you a survey regarding the care you and your
family member or friend received from this hospice. If you have already returned the survey to us,
please accept our thanks and disregard this letter. However, if you have not done so already, we
would greatly appreciate it if you would take the time to complete this important questionnaire.
We hope that you will take this opportunity to help us learn about the quality of care your family
member or friend received. The results from this survey will be used to help ensure that all
Americans get the highest quality hospice care.
Questions [NOTE THE QUESTION NUMBERS] in the enclosed survey are part of a national
initiative sponsored by the United States Department of Health and Human Services (HHS) to
measure the quality of care in hospices. The Centers for Medicare & Medicaid Services (CMS)
pays for most of the hospice care in the U.S. It is CMS’ responsibility to ensure that hospice
patients and their family members and friends get high quality care. One of the ways they can
fulfill this responsibility is to find out directly from you about the hospice care your family member
or friend received. Your participation is voluntary and will not affect any health care or benefits
you receive.
Please take a few minutes and complete the enclosed survey. After you have completed the survey,
please return it in the pre-paid envelope. Your answers may be shared with the hospice for purposes
of quality improvement. [OPTIONAL: 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.]
If you have any questions about the enclosed survey, please call the toll-free number 1-800-xxxxxxx. Thank you for helping to improve hospice care for all consumers.
Sincerely,
[HOSPICE ADMINISTRATOR]
[HOSPICE NAME]

December 2022

33

34

December 2022

OMB Paperwork Reduction Act Language
The OMB Paperwork Reduction Act language must appear in the mailing, either on the cover
letter or on the front or back of the questionnaire. In addition, the OMB control number must
appear on the front page of the questionnaire. 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 0938-1257 (Expires December 31, 2023). 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 212441850.”
Reply-by Date (Optional)
The following two options are available for adding a reply-by date to the follow-up cover
letter.
Placed above the salutation, such as:
Please reply by: [DATE (mm/dd/yyyy)].
In the fourth paragraph after the sentence, “After you have completed the survey, please return
it in the enclosed pre-paid envelope.” An example of allowable reply-by text includes:
Please fill out the enclosed survey and mail it by [DATE (mm/dd/yyyy)] in the pre-paid
envelope.

December 2022

35

36

December 2022