Form #2 Data Use Agreement

The CAHPS Health Plan Survey Database
Data Use Agreement
Instructions
1.

All organizations that want to participate in the CAHPS® Health Plan Survey Database must submit a signed Data
Use Agreement (DUA) and provide the organization name (hereinafter termed “Participating Organization”), and
the Participating Organization’s point of contact.
Data collection vendors may not sign this DUA on behalf of a health plan or participating sponsor organization
(even if they have been given permission by the health plan or participating sponsor organization to handle the
actual submission of data). Only a duly appointed representative from the health plan or participating sponsor
organization may sign this DUA.

2.

AHRQ’s Contractor, Westat, has pre-signed this Data Use Agreement (DUA) in its current form. Any changes or
modifications to the DUA other than those required to complete the DUA, such as contact information, will require
review and execution, by both parties, of a new DUA or addendum.

3.

This DUA includes important addenda requesting authorization from Participating Organizations to use measures
from the CAHPS Health Plan Survey data they provide to the CAHPS Database for purposes of reporting state-level
Medicaid and/or Children’s Health Insurance Program (CHIP) CAHPS Health Plan Survey results in specific private
and public reporting products.
• HEALTH PLANS: If you are a health plan submitting data, and you are not a State agency, please complete the
reporting authorization requests in Addendum A on page 5.
• STATE AGENCIES: If you are a State agency submitting data, please complete the reporting authorization

requests in Addendum B on page 6.

4. Please sign and upload a scanned copy of the signed DUA by logging into the data submission system at
https://cahpsdatabase.ahrq.gov/HPDSS/login.aspx and selecting the DUA tab.
5.

Please retain a copy of the fully signed and executed DUA for your records.

If you have any questions or require any additional information please contact the CAHPS Database at 888-808-7108
or by email at [email protected].

Form Approved: OMB No.: 0935-0165
Exp. Date: 05/31/2020

The CAHPS Health Plan Survey Database
Data Use Agreement
1.

This Data Use Agreement (DUA) is made by and between the Agency for Healthcare Research and Quality (AHRQ), AHRQ’s
contractor, Westat, and the organization named below (hereinafter termed “Participating Organization”) which includes any
health plan listed under item 13 on page 3 of this DUA.
Name of Participating Organization

Street Address of Participating Organization

City

State

Zip Code

VERY IMPORTANT: Type or write in the name of the Participating Organization above. If more than one health
plan is represented, list the name of the participating sponsor organization above, and under item 13, page 3
of this DUA, IDENTIFY EACH INDIVIDUAL HEALTH PLAN for which data will be submitted.
2.

AHRQ’s Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Database is a central repository of data on
health plan, medical group, clinician, and health care facility performance as measured by a selected set of CAHPS surveys.
This DUA specifies the terms and conditions of Participating Organization’s submission of its CAHPS Health Plan Survey data
to Westat for participation in the CAHPS Health Plan Survey Database (hereinafter termed the “Database”).

3.

The Database is populated with CAHPS Health Plan Survey data through the voluntary participation of organizations that have
administered the CAHPS Health Plan Survey and are willing to submit their CAHPS Health Plan Survey data to AHRQ for
inclusion in the Database. Because participating organizations (e.g., State agencies, health plans, medical groups, clinicians)
voluntarily submit data to the CAHPS Database, the Data do not constitute a nationally representative sample.
The Database is funded by the Agency for Healthcare Research and Quality (AHRQ) and managed and administered by
AHRQ’s contractor, Westat (hereinafter termed the “Contractor”). AHRQ’s Contractor will operate the Database to comply
with the provisions in this DUA.

4.

Participating Organizations will provide their CAHPS Health Plan Survey data to the Database for AHRQ’s research, analysis
and reporting programs according to the terms specified in this DUA. By agreeing to participate in the Database, each
Participating Organization agrees to make every good faith effort to provide data for inclusion in the Database, as specified by
the data specifications outlined below. The data provided for inclusion in the Database are collectively referred to as the
“Data.” Participating Organization’s Data include:
a)

A copy of the final CAHPS Health Plan Survey instrument(s) administered, including copies of paper and/or web- based
versions as applicable, for each surveyed population for which data will be submitted to the Database showing all survey
instructions and items administered. If more than one version of the CAHPS Health Plan Survey was administered, a copy
of each CAHPS Health Plan Survey instrument administered must be provided with the corresponding results for each
version of the survey instrument for which data are submitted;

Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time required to
complete the form. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of
information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction
Project (0935-0165) AHRQ, 5600 Fishers Lane, Rockville, MD 20857.

Data Use Agreement – CAHPS Health Plan Survey Database

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Form Approved: OMB No.: 0935-0165
Exp. Date: 05/31/2020

b)

Respondent-level CAHPS Health Plan Survey data that are de-identified to prevent identification of any individual in the
Database. Participating Organization will submit its final, de-identified respondent-level CAHPS Health Plan Survey data,
as collected by the Participating Organization itself or by a survey data collection vendor, according to the data
specifications outlined for the Database; and

c)

Selected survey administration and organizational characteristics data (e.g., state, mode of survey administration, dates
of administration, sample size, response rates, etc.).

5.

AHRQ’s Contractor agrees to establish appropriate and necessary administrative, technical, and physical procedures and
safeguards including limiting access to the Data and providing appropriate staff training to protect the confidentiality of the
Data and to prevent the unauthorized use of it or access to it. Only AHRQ’s Contractor and duly authorized representatives
appointed by AHRQ will have access to the identifiable source Data provided by Participating Organization.

6.

Participating Organization’s Data will be accepted into the Database provided that the version of the CAHPS Health Plan
Survey administered is deemed acceptable by AHRQ’s Contractor, (i.e., not modified from the original CAHPS Health Plan
Survey instructions and items) and the Data submitted by Participating Organization are deemed acceptable. AHRQ’s
Contractor will promptly notify the Participating Organization of any problem with the survey version(s) administered or with
the Data submitted. If the survey version administered is acceptable but the Data submitted are problematic, AHRQ’s
Contractor will make a good faith effort to work with the Participating Organization to complete or correct the data
submission, but reserves the right to not include incompatible or flawed Data in the Database.

7.

Participating Organization’s Data will be used for AHRQ’s research, analysis, and reporting programs, and the Data will be
aggregated along with other Participating Organizations’ Data in the Database. AHRQ will publicly report aggregated statistics
overall and at the state level on the CAHPS Health Plan Survey composite scores and items, and present statistics by various
organizational characteristics (e.g., product type and region), using data from Participating Organizations. Only aggregated
data will be publicly reported, and only when there are sufficient data so that such aggregation will not permit the
identification of individual respondents or health plans by other Participating Organizations or the public, with the exception
that in the event that only one health plan’s data are submitted for a given state, and the Participating Organization for that
health plan authorizes the use of its CAHPS Health Plan data for state-level reporting, that one health plan’s results will be
displayed in state level results in the CAHPS Database in a way that might enable the identification of that health plan. Results
will be made available publicly at no charge.

8.

AHRQ’s Contractor conducts analyses of the Data to examine its distributional properties (variability, missing data, skewness),
to assess the factor structure and reliability of the items and composites, and examine relationships of the Data with
organizational characteristics. In any data analysis reports that may be produced, such reports will not identify individual
Participating Organizations by name and results will only be reported in a manner that will not permit the identification of
Participating Organizations.

9.

AHRQ and its Contractor, Westat, agree to use the Data submitted by Participating Organization only for the purposes stated
in this DUA.

10. Researcher Access to Participating Organization’s Data. The AHRQ confidentiality statute, Section 944(c) of the Public Health
Service Act (42 U.S.C. 299c-3(c)), requires that data collected by AHRQ or one of its contractors (including Westat) that
identify establishments be used only for the purposes for which the data were supplied. AHRQ may grant researchers access
to Participating Organizations’ de-identified Data according to the following provisions:
a)

Access to respondent and organization level data files that do not identify or permit re-identification of individual
respondents or Participating Organizations may be granted by AHRQ without the specific authorization of Participating
Organizations whose Data are included as part of the data files. Individuals requesting de-identified CAHPS Health Plan
Survey data (hereinafter termed “Data Requesters”) must submit a Research Abstract Form detailing the research
purpose, hypotheses and methodology for analyzing the Data. AHRQ will review all Research Abstract Forms and
approve or deny the requests. Data Requesters must also sign a Data Release Agreement in which they agree with the
following requirements. Data Requesters agree that they: 1) will not use, and will prohibit others from using or
disclosing, the de-identified Data except for the purposes specified in their Research Abstract Form; 2) will ensure that

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Form Approved: OMB No.: 0935-0165
Exp. Date: 05/31/2020

the de-identified Data are kept in a secured environment and that only authorized users will have access to it; and 3) will
limit the use of the de-identified Data to the individuals who require access in order to perform activities for the
purposes specified in the Research Abstract Form.
b)

The de-identified data files may include organizational characteristics (e.g., product type and region), provided the
characteristics do not permit re-identification of individual respondents or Participating Organizations. Participating
Organizations will not be identified by name in the research data set, except in the event that only one health plan’s
data are submitted for a given state, that one health plan’s results will be included in the research data set in a way
that might enable the identification of that health plan. By authorizing the use of its Data for state-level reporting and
signing this DUA, the Participating Organization consents to such disclosure. However, as noted in item 10a, data
requesters sign a Data Release Agreement in which they agree they will not use the research data for public reporting
and will not report, through any medium, data that could identify, directly or by inference, individual Participating
Organizations.

c)

Access to data files specific to an identifiable Participating Organization may be approved only with the express written
authorization of the Participating Organization whose data files are requested (except as noted in item 10b, in the event
that only one health plan’s data are submitted for a given state, that one health plan’s results will be included in the
research data set in a way that might enable the identification of that health plan). However, results containing any
identifying information may not be released, disclosed or made public without the express written authorization of any
Participating Organizations that may be identified in the published research analysis.

d)

Valid purposes for the use of CAHPS Health Plan Survey de-identifiable or identifiable research data sets do not include
the use of Data for public reporting, proprietary, commercial or competitive purposes involving those Participating
Organizations, or to determine the rights, benefits, or privileges of Participating Organizations.

11. AHRQ’s Contractor, Westat, has signed this DUA in its current form. Any changes or modifications to the DUA other than
those required to complete the DUA, such as contact information, will require review and execution, by both parties, of a new
DUA or addendum.
12. Participating Organization may change or revoke this consent by sending written notification to the CAHPS Database, Westat,
1600 Research Boulevard, Rockville, MD 20850. Requests for changes or revocations must be received within 2 weeks of the
current year’s data submission deadline to be excluded from the current year’s database and all reporting for that year. The
request for revocation will not apply to Data already authorized and released prior to receipt of a written request to revoke
consent.
13. If Participating Organization represents more than one health plan, use the space below to (1) TYPE OR WRITE THE NAME OF
EACH INDIVIDUAL HEALTH PLAN, (2) TYPE OR WRITE ITS ADDRESS, INCLUDING CITY AND STATE, AND (3) CHECK (X)
WHETHER THE HEALTH PLAN IS AN ADULT MEDICAID, CHILD MEDICAID, OR CHIP PLAN which is represented by the
Participating Organization and therefore covered under this Data Use Agreement. Attach additional sheet(s) if necessary.

Name of Health Plan

Address, City and State

Data Use Agreement – CAHPS Health Plan Survey Database

Adult
Medicaid

Child
Medicaid

CHIP

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Form Approved: OMB No.: 0935-0165
Exp. Date: 05/31/2020

14. If you are a State agency submitting Medicaid and/or CHIP program data, please provide the following information:

a. Total Number of Plans in Your State (If you don’t know the number of plans in your state please write “Don’t know”).
Adult
Medicaid

Child
Medicaid

CHIP

b. Are You Submitting Data For All of the Medicaid/CHIP Programs in Your State? (Check Yes, No or Don’t know.)
Adult
Medicaid

Yes
No
Don’t know

Child
Medicaid

Yes
No
Don’t know

CHIP

Yes
No
Don’t know

15. Please complete the information below, sign, and return all pages of this data use agreement to Westat.
The undersigned individual hereby attests that he/she is duly authorized to represent the Participating Organization and all
health plans listed under item 13 and in so doing, enters into this Data Use Agreement on behalf of the Participating
Organization and the health plans listed under item 13 and agrees to all the terms specified herein.
Complete all
information
Name:
Title:
Address:
Phone number:

Fax number:

Email address:
Sign and
Date
(Signature)

(Date)

16. Name and Address of Participating Organization Contact for this DUA (if different from above):
Complete
as needed
Name of contact:
Title:
Address:
Phone number:

Fax number:

Email address:

The undersigned individual hereby attests that he/she is duly authorized to represent Westat, AHRQ’s Contractor, and, in so doing,
enters into this Data Use Agreement on behalf of Westat and agrees to all the terms specified herein.
Digitally signed by lois olinger
Date: 2019.05.14 13:07:52 -04'00'

Lois Olinger, Vice President, Westat
Data Use Agreement – CAHPS Health Plan Survey Database

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Form Approved: OMB No.: 0935-0165
Exp. Date: 05/31/2020

DUA Addendum A: For Health Plans Only
To Provide Authorization for Use of CAHPS Health Plan Survey Data
for State-Level Private and Public Reporting
The U.S. Agency for Healthcare Research and Quality (AHRQ) is requesting authorization from individual health plans to
use measures from the CAHPS Health Plan Survey data they provide to the CAHPS Database for purposes of reporting
state-level Medicaid and/or CHIP CAHPS Health Plan Survey results in the following private and public reporting
products:
1) State-level public reporting for the AHRQ CAHPS Database;
2) State-level public reporting by the Centers for Medicare & Medicaid Services (CMS) on Medicaid.gov and
Data.Medicaid.gov; and
3) State-level private report to be provided to your State agency.

Addendum A1. State-level public reporting for the AHRQ CAHPS Database that will not display the name of
your health plan(s)
Please initial one:
_____ YES: Authorization is hereby granted to AHRQ to use the CAHPS Health Plan Survey data we provide to
the AHRQ CAHPS Database to present state-level Medicaid and/or CHIP CAHPS Health Plan Survey
results in the public reporting products of the AHRQ CAHPS Database (including the annual CAHPS
Health Plan Survey Chartbook and the Online Reporting System).
_____ NO: Authorization is not granted for the requested use of our CAHPS Health Plan Survey data.

Addendum A2. State-level public reporting on Medicaid.gov and Data.Medicaid.gov that will not display the
name of your health plan(s)
Please initial one:
_____ YES: Authorization is hereby granted to AHRQ to release to CMS the CAHPS Health Plan Survey data we
provide to AHRQ’s CAHPS Database to allow CMS to publicly report state-level Medicaid and/or CHIP
CAHPS Health Plan Survey results on CMS’s Medicaid.gov and Data.Medicaid.gov.
_____ NO: Authorization is not granted for the requested use of our CAHPS Health Plan Survey data.

Addendum A3. Release of plan-identifiable results to your State agency for state-level private reporting
Please initial one:
_____ YES: Authorization is hereby granted to include results for my health plan(s) in a private report to be
provided to my State agency. This private report will display results for each health plan within my state
that authorizes the release of their results to the State agency. Plan-identifiable results will be displayed
in the private report using the name of each health plan.
_____ NO: Authorization is not granted for the requested use of our CAHPS Health Plan Survey data.

Data Use Agreement – CAHPS Health Plan Survey Database

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Form Approved: OMB No.: 0935-0165
Exp. Date: 05/31/2020

DUA Addendum B: For State Agencies Only
To Provide Authorization for Use of CAHPS Health Plan Survey Data
for State-Level Public Reporting
The U.S. Agency for Healthcare Research and Quality (AHRQ) is requesting authorization from State agencies to use
measures from the CAHPS Health Plan Survey data they provide to the CAHPS Database for purposes of reporting statelevel Medicaid and/or CHIP CAHPS Health Plan Survey results in the following public reporting products:
1) State-level public reporting for the AHRQ CAHPS Database;
2) State-level public reporting for the AHRQ National Healthcare Quality and Disparities Report;
3) State-level public reporting by the Centers for Medicare & Medicaid Services (CMS) on Medicaid.gov and
Data.Medicaid.gov.

Addendum B1. State-level public reporting for the AHRQ CAHPS Database that will not display the name
of your health plan(s)
Please initial one:
_____ YES: Authorization is hereby granted to AHRQ to use the CAHPS Health Plan Survey data we provide to
the AHRQ CAHPS Database to present state-level Medicaid and/or CHIP CAHPS Health Plan Survey
results in the public reporting products of the AHRQ CAHPS Database (including the annual CAHPS
Health Plan Survey Chartbook and the Online Reporting System).
_____ NO: Authorization is not granted for the requested use of our CAHPS Health Plan Survey data.

Addendum B2. State-level public reporting for the AHRQ National Healthcare Quality and Disparities Report
that will not display the name of your health plan(s)
Please initial one:
_____ YES: Authorization is hereby granted to AHRQ to use the CAHPS Health Plan Survey data we provide to
the CAHPS Database to publicly report state-level Medicaid CAHPS Health Plan Survey results in AHRQ’s
National Healthcare Quality and Disparities Report.
_____ NO: Authorization is not granted for the requested use of our CAHPS Health Plan Survey data.

Addendum B3. State-level public reporting on Medicaid.gov and Data.Medicaid.gov that will not display
the name of your health plan(s)
Please initial one:
_____ YES: Authorization is hereby granted to AHRQ to release to CMS the CAHPS Health Plan Survey data we
provide to AHRQ’s CAHPS Database to allow CMS to publicly report state-level Medicaid and/or CHIP
CAHPS Health Plan Survey results on CMS’s Medicaid.gov and Data.Medicaid.gov.
_____ NO: Authorization is not granted for the requested use of our CAHPS Health Plan Survey data.
Data Use Agreement – CAHPS Health Plan Survey Database

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