Form CMS-10102 HCAHPS Survey Instrument (Mail) and Supporting Materials

HCAHPS Survey
SURVEY INSTRUCTIONS
♦
♦
♦

You should only fill out this survey if you were the patient during the hospital stay
named in the cover letter. Do not fill out this survey if you were not the patient.
Answer all the questions by checking 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:



Yes
No  If No, Go to Question 1

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.
Please note: Questions 1-29 in this survey are part of a national initiative to measure the quality
of care in hospitals. OMB #0938-0981 (Expires September 30, 2024)

Please answer the questions in this survey
about your stay at the hospital named on
the cover letter. Do not include any other
hospital stays in your answers.

3.

 Never
 Sometimes
3 Usually
4 Always
1
2

YOUR CARE FROM NURSES
1.

During this hospital stay, how often
did nurses treat you with courtesy
and respect?

 Never
2 Sometimes
3 Usually
4 Always
1

2.

During this hospital stay, how often
did nurses listen carefully to you?

 Never
2 Sometimes
3 Usually
4 Always
1

March 2023

During this hospital stay, how often
did nurses explain things in a way
you could understand?

4.

During this hospital stay, after you
pressed the call button, how often did
you get help as soon as you wanted
it?

 Never
 Sometimes
3 Usually
4 Always
9 I never pressed the call button
1
2

1

YOUR CARE FROM DOCTORS
5.

During this hospital stay, how often
did doctors treat you with courtesy
and respect?

 Never
2 Sometimes
3 Usually
4 Always
1

6.

During this hospital stay, how often
did doctors listen carefully to you?

 Never
2 Sometimes
3 Usually
4 Always
1

7.

During this hospital stay, how often
did doctors explain things in a way
you could understand?

 Never
2 Sometimes
3 Usually
4 Always
1

THE HOSPITAL ENVIRONMENT
8.

During this hospital stay, how often
were your room and bathroom kept
clean?

 Never
2 Sometimes
3 Usually
4 Always
1

9.

During this hospital stay, how often
was the area around your room quiet
at night?

 Never
 Sometimes
3 Usually
4 Always
1
2

2

YOUR EXPERIENCES IN THIS HOSPITAL
10. During this hospital stay, did you
need help from nurses or other
hospital staff in getting to the
bathroom or in using a bedpan?

 Yes
 No  If No, Go to Question 12

1

2

11. How often did you get help in getting
to the bathroom or in using a bedpan
as soon as you wanted?

 Never
 Sometimes
3 Usually
4 Always
1
2

12. During this hospital stay, were you
given any medicine that you had not
taken before?

 Yes
2 No  If No, Go to Question 15

1

13. Before giving you any new medicine,
how often did hospital staff tell you
what the medicine was for?

 Never
 Sometimes
3 Usually
4 Always
1
2

14. Before giving you any new medicine,
how often did hospital staff describe
possible side effects in a way you
could understand?

 Never
2 Sometimes
3 Usually
4 Always
1

March 2023

WHEN YOU LEFT THE HOSPITAL
15. After you left the hospital, did you go
directly to your own home, to
someone else’s home, or to another
health facility?

 Own home
2 Someone else’s home
3 Another health
1

facility  If Another, Go to
Question 18

16. During this hospital stay, did doctors,
nurses or other hospital staff talk with
you about whether you would have
the help you needed when you left the
hospital?

 Yes
 No

1
2

17. During this hospital stay, did you get
information in writing about what
symptoms or health problems to look
out for after you left the hospital?

 Yes
 No

1
2

OVERALL RATING OF HOSPITAL
Please answer the following questions
about your stay at the hospital named on
the cover letter. Do not include any other
hospital stays in your answers.
18. Using any number from 0 to 10, where
0 is the worst hospital possible and
10 is the best hospital possible, what
number would you use to rate this
hospital during your stay?

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

Worst hospital possible

Best hospital possible

19. Would you recommend this hospital
to your friends and family?
1 Definitely no
2 Probably no
3 Probably yes
4 Definitely yes

UNDERSTANDING YOUR CARE
WHEN YOU LEFT THE HOSPITAL
20. During this hospital stay, staff took
my preferences and those of my
family or caregiver into account in
deciding what my health care needs
would be when I left.

 Strongly disagree
2 Disagree
3 Agree
4 Strongly agree
1

March 2023

3

21. When I left the hospital, I had a good
understanding of the things I was
responsible for in managing my
health.
1 Strongly disagree
2 Disagree
3 Agree
4 Strongly agree
22. When I left the hospital, I clearly
understood the purpose for taking
each of my medications.

 Strongly disagree
 Disagree
3 Agree
4 Strongly agree
5 I was not given any medication when
1
2

I left the hospital

ABOUT YOU
There are only a few remaining items left.
23. During this hospital stay, were you
admitted to this hospital through the
Emergency Room?

 Yes
2 No
1

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

 Excellent
2 Very good
3 Good
4 Fair
5 Poor
1

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

 Excellent
2 Very good
3 Good
4 Fair
5 Poor
1

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

 8th grade or less
 Some high school, but did not

1
2


4
5
6
3

27. Are you of Spanish, Hispanic or
Latino origin or descent?

 No, not Spanish/Hispanic/Latino
 Yes, Puerto Rican
3 Yes, Mexican, Mexican American,
1
2

Chicano
 Yes, Cuban
5 Yes, other Spanish/Hispanic/Latino
4

28. What is your race? Please choose one
or more.

 White
 Black or African American
3 Asian
4 Native Hawaiian or other Pacific
1
2



5

4

graduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree

Islander
American Indian or Alaska Native

March 2023

29. What language do you mainly speak
at home?


2
3
4
5
6
7
8
9
20
1

English
Spanish
Chinese
Russian
Vietnamese
Portuguese
German
Tagalog
Arabic
Some other language (please
print): _____________________

NOTE: IF HOSPITAL-SPECIFIC
SUPPLEMENTAL QUESTION(S) ARE
ADDED, THE MANDATORY TRANSITION
STATEMENT MUST BE PLACED
IMMEDIATELY BEFORE THE
SUPPLEMENTAL QUESTION(S).

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

Questions 1-19 and 23-29 are part of the HCAHPS Survey and are works of the U.S. Government.
These HCAHPS questions are in the public domain and therefore are NOT subject to U.S.
copyright laws. The three Care Transitions Measure® questions (Questions 20-22) are copyright
of Eric A. Coleman, MD, MPH, all rights reserved.

March 2023

5

6

March 2023

HCAHPS Survey
SURVEY INSTRUCTIONS
♦
♦
♦

You should only fill out this survey if you were the patient during the hospital stay named in the
cover letter. Do not fill out this survey if you were not the patient.
Answer all the questions by completely filling in the circle 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:

0
0

Yes
No  If No, Go to Question 1

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.
Please note: Questions 1-29 in this survey are part of a national initiative to measure the quality of care
in hospitals. OMB #0938-0981 (Expires September 30, 2024)

Please answer the questions in this survey
about your stay at the hospital named on
the cover letter. Do not include any other
hospital stays in your answers.

3.

0
20
30
40
1

YOUR CARE FROM NURSES
1.

During this hospital stay, how often
did nurses treat you with courtesy
and respect?

0
20
30
40
1

2.

Never
Sometimes
Usually
Always

During this hospital stay, how often
did nurses listen carefully to you?

0
20
30
40
1

Never
Sometimes

During this hospital stay, how often
did nurses explain things in a way
you could understand?

4.

Never
Sometimes
Usually
Always

During this hospital stay, after you
pressed the call button, how often did
you get help as soon as you wanted
it?

0
20
30
40
90
1

Never
Sometimes
Usually
Always
I never pressed the call button

Usually
Always

March 2023

7

YOUR CARE FROM DOCTORS
5.

During this hospital stay, how often
did doctors treat you with courtesy
and respect?

0
20
30
40
1

6.

Sometimes
Usually
Always

During this hospital stay, how often
did doctors listen carefully to you?

0
0
30
40
7.

Never

0
0
30
40
1

Never

2

Sometimes
Usually
Always

YOUR EXPERIENCES IN THIS HOSPITAL
10. During this hospital stay, did you
need help from nurses or other
hospital staff in getting to the
bathroom or in using a bedpan?

Never

2

Sometimes

1

Usually

Yes

2

No  If No, Go to Question 12

Always

During this hospital stay, how often
did doctors explain things in a way
you could understand?

0
20
30
40

Never
Sometimes
Usually
Always

THE HOSPITAL ENVIRONMENT
During this hospital stay, how often
were your room and bathroom kept
clean?

0
0
30
40

8

During this hospital stay, how often
was the area around your room quiet
at night?

1

1

8.

9.

1

Never

2

Sometimes
Usually
Always

0
0

11. How often did you get help in getting
to the bathroom or in using a bedpan
as soon as you wanted?

0
20
30
40
1

Never
Sometimes
Usually
Always

12. During this hospital stay, were you
given any medicine that you had not
taken before?

0
0

1

Yes

2

No  If No, Go to Question 15

13. Before giving you any new medicine,
how often did hospital staff tell you
what the medicine was for?

0
0
30
40
1

Never

2

Sometimes
Usually
Always

March 2023

14. Before giving you any new medicine,
how often did hospital staff describe
possible side effects in a way you
could understand?

0
20
30
40
1

Never
Sometimes
Usually
Always

WHEN YOU LEFT THE HOSPITAL
15. After you left the hospital, did you go
directly to your own home, to
someone else’s home, or to another
health facility?

0
20
30
1

Own home
Someone else’s home
Another health
facility  If Another, Go to
Question 18

16. During this hospital stay, did doctors,
nurses or other hospital staff talk with
you about whether you would have
the help you needed when you left the
hospital?

0
20
1

0
20

Please answer the following questions
about your stay at the hospital named on
the cover letter. Do not include any other
hospital stays in your answers.
18. Using any number from 0 to 10, where
0 is the worst hospital possible and
10 is the best hospital possible, what
number would you use to rate this
hospital during your stay?

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

0

1

1

Worst hospital possible

2
3
4
5
6
7
8
9
10

Best hospital possible

19. Would you recommend this hospital
to your friends and family?

0
0
30
40

Yes

1

Definitely no

No

2

Probably no

17. During this hospital stay, did you get
information in writing about what
symptoms or health problems to look
out for after you left the hospital?
1

OVERALL RATING OF HOSPITAL

Yes
No

Definitely yes

UNDERSTANDING YOUR CARE
WHEN YOU LEFT THE HOSPITAL
20. During this hospital stay, staff took
my preferences and those of my
family or caregiver into account in
deciding what my health care needs
would be when I left.

0
0
30
40
March 2023

Probably yes

1

Strongly disagree

2

Disagree
Agree
Strongly agree
9

21. When I left the hospital, I had a good
understanding of the things I was
responsible for in managing my
health.

0
20
30
40
1

Strongly disagree
Disagree
Agree
Strongly agree

22. When I left the hospital, I clearly
understood the purpose for taking
each of my medications.

0
20
30
40
50
1

Strongly disagree
Disagree
Agree
Strongly agree
I was not given any medication when
I left the hospital

ABOUT YOU
There are only a few remaining items left.
23. During this hospital stay, were you
admitted to this hospital through the
Emergency Room?

0
0

1

Yes

2

No

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

0
0
30
40
50
1

Excellent

2

Very good
Good
Fair
Poor

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

0
20
30
40
50
1

Very good
Good
Fair
Poor

26. 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

27. Are you of Spanish, Hispanic or
Latino origin or descent?

0
0
30
1

No, not Spanish/Hispanic/Latino

2

Yes, Puerto Rican

0
50
4

Yes, Mexican, Mexican American,
Chicano
Yes, Cuban
Yes, other Spanish/Hispanic/Latino

28. What is your race? Please choose one
or more.

0
20
30
40
1

0

5

10

Excellent

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

March 2023

29. What language do you mainly speak
at home?

0 English
20 Spanish
30 Chinese
40 Russian
50 Vietnamese
60 Portuguese
70 German
80 Tagalog
90 Arabic
200 Some other language (please print):
1

_____________________

NOTE: IF HOSPITAL-SPECIFIC
SUPPLEMENTAL QUESTION(S) ARE
ADDED, THE MANDATORY TRANSITION
STATEMENT MUST BE PLACED
IMMEDIATELY BEFORE THE
SUPPLEMENTAL QUESTION(S).

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

Questions 1-19 and 23-29 are part of the HCAHPS Survey and are works of the U.S. Government.
These HCAHPS questions are in the public domain and therefore are NOT subject to U.S.
copyright laws. The three Care Transitions Measure® questions (Questions 20-22) are copyright
of Eric A. Coleman, MD, MPH, all rights reserved.

March 2023

11

12

March 2023

Sample Initial Cover Letter for the HCAHPS Survey
[HOSPITAL LETTERHEAD]
[SAMPLED PATIENT NAME]
[ADDRESS]
[CITY, STATE ZIP]
Dear [SAMPLED PATIENT NAME]:
Our records show that you were recently a patient at [NAME OF HOSPITAL] and discharged on
[DATE OF DISCHARGE (mm/dd/yyyy)]. Because you had a recent hospital stay, we are asking
for your help.
The enclosed survey is part of an effort to understand how patients view their hospital care.
Questions 1-29 in the survey are sponsored by the United States Department of Health and Human
Services and should take about 7 minutes to complete.
Your participation is voluntary and your answers will be kept private. Your responses will help
improve the quality of hospital care and help other people make more informed choices about their
care. You can see current survey results and find hospital ratings on Care Compare on Medicare.gov
(www.medicare.gov/care-compare).
After you have completed the survey, please return it in the enclosed pre-paid envelope. If you have
any questions about the survey, please call this toll-free number: 1-xxx-xxx-xxxx.
We greatly appreciate your help in improving hospital care.
Sincerely,
[HOSPITAL ADMINISTRATOR]
[HOSPITAL NAME]

March 2023

13

14

March 2023

Sample Follow-up Cover Letter for the HCAHPS Survey
[HOSPITAL LETTERHEAD]
[SAMPLED PATIENT NAME]
[ADDRESS]
[CITY, STATE ZIP]
Dear [SAMPLED PATIENT NAME]:
A few weeks ago, we sent you a survey asking for your feedback on your recent experience at
[NAME OF HOSPITAL] discharged on [DATE OF DISCHARGE (mm/dd/yyyy)]. If you have
already returned the survey to us, please accept our thanks and disregard this letter. However, if you
have not yet completed the survey, please take a few minutes and complete it now.
The enclosed survey is part of an effort to understand how patients view their hospital care.
Questions 1-29 in the survey are sponsored by the United States Department of Health and Human
Services and should take about 7 minutes to complete.
Your participation is voluntary and your answers will be kept private. Your responses will help
improve the quality of hospital care and help other people make more informed choices about their
care. You can see current survey results and find hospital ratings on Care Compare on Medicare.gov
(www.medicare.gov/care-compare).
After you have completed the survey, please return it in the enclosed pre-paid envelope. If you have
any questions about the survey, please call this toll-free number: 1-xxx-xxx-xxxx.
We greatly appreciate your help in improving hospital care.
Sincerely,
[HOSPITAL ADMINISTRATOR]
[HOSPITAL NAME]

March 2023

15

16

March 2023

Survey and Cover Letter Required Language
For the full set of requirements for the HCAHPS Survey questionnaire and cover letters, please see
the HCAHPS Quality Assurance Guidelines, Mail Only and Mixed Mode Survey Administration
chapters.
Verbatim Language on the Cover Letters
The following sentences must appear verbatim on each cover letter:
1. Questions 1-29 in the survey are sponsored by the United States Department of Health
and Human Services and should take about 7 minutes to complete.
2. Your participation is voluntary and your answers will be kept private.
3. Your responses will help improve the quality of hospital care and help other people make
more informed choices about their care. You can see current survey results and find
hospital ratings on Care Compare on Medicare.gov (www.medicare.gov/care-compare).
OMB Paperwork Reduction Act Language
The OMB Paperwork Reduction Act language must appear verbatim either on the front or back
of the questionnaire (preferred) or cover letter, but cannot be a separate mailing. The following
is the language that must be used:
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 0938-0981 (Expires September 30, 2024).
The time required to complete this information collected is estimated to average 7 minutes
for questions 1-29 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.
Mandatory Transition Statement if Supplemental Items Are Added
The mandatory transition statement must be placed in the questionnaire immediately before the
supplemental question(s) to indicate a transition from the HCAHPS questions (Questions 1-29)
to the hospital-specific supplemental question or questions.
The following statement must be placed immediately before the addition of a single supplemental
question:
Questions 1-29 in this survey are from the U.S. Department of Health and Human
Services (HHS) for use in quality measurement. The following question is from [NAME
OF HOSPITAL] to gather additional feedback about your hospital stay and will not be
shared with HHS.
The following statement must be placed immediately before the addition of more than one
supplemental question:
Questions 1-29 in this survey are from the U.S. Department of Health and Human
Services (HHS) for use in quality measurement. The following questions are from
[NAME OF HOSPITAL] to gather additional feedback about your hospital stay and
will not be shared with HHS.
March 2023

17

Unique Identifier Language
The following language indicates the purpose of the unique identifier. This language must be
printed either immediately after the survey instructions on the questionnaire (preferred) or on
the cover letter, and may appear on both:
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.
Copyright Statement
The following copyright statement must be included on the questionnaire, preferably on the last
page:
Questions 1-19 and 23-29 are part of the HCAHPS Survey and are works of the U.S.
Government. These HCAHPS questions are in the public domain and therefore are NOT
subject to U.S. copyright laws. The three Care Transitions Measure® questions (Questions
20-22) are copyright of Eric A. Coleman, MD, MPH, all rights reserved.
Reply-by Date (Optional)
It is optional to include a reply-by date in the follow-up cover letter. However, if a reply-by date
is included, the placement requirements below must be followed.
The following two placement options are available for adding a reply-by date to the follow-up
cover letter:
1. Placed above the salutation, such as:
Please reply by: [DATE (mm/dd/yyyy)].
2. In the fourth paragraph replace the sentence, “After you have completed the survey,
please return it in the enclosed pre-paid envelope” with reply-by text such as:
Please fill out the enclosed survey and mail it by [DATE (mm/dd/yyyy)] in the pre-paid
envelope.

18

March 2023