CMS-10500 OAS CAHPS (Web Survey Screenshots)

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

EXAMPLE LANDING PAGE, IF GENERIC WEB SURVEY URL USED

OAS CAHPS® Survey
Please input your Survey Access code.
Por favor ingrese su código de acceso.

Take the Survey / Responder la encuesta

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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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-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 November 30, 2024. 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.

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CONFIRM – LOGIC AFTER: 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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-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. All information you provide is
confidential and is protected by the Privacy Act.

Questions? Contact [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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Q4

OAS CAHPS® Survey
ABOUT THE FACILITY AND STAFF

Was the facility clean?

o Yes, definitely
o Yes, somewhat
o No

Questions? Contact [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

Q5

OAS CAHPS® Survey
ABOUT THE FACILITY AND STAFF

Were the clerks and receptionists at the facility as helpful as you thought they should
be?

o Yes, definitely
o Yes, somewhat
o No

Questions? Contact [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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Q6

OAS CAHPS® Survey
ABOUT THE FACILITY AND STAFF

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

o Yes, definitely
o Yes, somewhat
o No

Questions? Contact [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-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 get written discharge instructions?

o Yes
o No

Questions? Contact [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

Q29

OAS CAHPS® Survey
ABOUT YOU

Which group best describes you?

o
o
o
o

Questions? Contact [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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Q30

OAS CAHPS® Survey
ABOUT YOU

What is your race? You may select one or more categories.

o
o
o
o
o

Questions? Contact [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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.

o
o
o
o
o
o
o
o

Questions? Contact [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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.

o
o
o
o
o

Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
None of the above

Questions? Contact [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

Q31

OAS CAHPS® Survey
ABOUT YOU

How well do you speak English?

o
o
o
o

Questions? Contact [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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Q34

OAS CAHPS® Survey
ABOUT YOU

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

o Read the questions to me
o Entered the answers I gave
o Answered the questions for me
o Translated the questions into my language
o Helped in some other way (Please explain):
o No one helped me complete this survey

Questions? Contact [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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Q_INELIG

PRELOGIC: DOB DOES NOT MATCH WHAT IS IN HOPD/ASC PATIENT 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 [VENDOR NAME] via email at [VENDOR EMAIL ADDRESS] or call toll-free 1-800-XXX-XXXX.

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