CMS-10102 HCAHPS Survey Instrument (Telephone Script)

ATTACHMENT C
HCAHPS CATI Script
(English)

HCAHPS
DRAFT Phone Script (English)
Survey content subject to pending rulemaking August 2024
Script Conventions and Programming Instructions
Formatting and Programming
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•

•

[Square brackets] are used to show programming instructions that must not actually
appear on electronic telephone interviewing system screens
Only one language (i.e., English, Spanish, Chinese, or Russian) must appear on the
electronic interviewing system screen
No changes are permitted to the wording or order of the HCAHPS Survey questions
(Questions 1-32) or the response categories
All transitional phrases must be read
Text that is underlined must be emphasized
Characters in < > brackets must not be read
All questions are programmed to accept only one response, with the exception of Question
32
Response categories must not be pre-coded or default coded
MISSING/DON’T KNOW (DK) is a valid response option for each item in the electronic
telephone interviewing system script; however, this option must not be read out loud to the
patient. MISSING/DK response categories allow the phone interviewer to go to the next
question if a patient is unable to provide a response for a given question (or refuses to
provide a response). In the survey file layouts, a value of MISSING/DK is coded as “M Missing/Don't know.”
Skip patterns should be programmed into the electronic telephone interviewing system
o Appropriately skipped questions should be coded as “8 - Not applicable.” For
example, if a patient answers “No” to Question 12 of the HCAHPS Survey, the
program should skip Question 13, and go to Question 14. Question 13 must then
be coded as “8 - Not applicable.” Coding may be done automatically by the
telephone interviewing system or later during data preparation.
o When a response to a screener question is not obtained, the screener question and
any questions in the skip pattern should be coded as “M - Missing/Don't know.”
For example, if the patient does not provide an answer to Question 12 of the
HCAHPS Survey and the interviewer selects “MISSING/DON’T KNOW” to
Question 12, then the telephone interviewing system should be programmed to skip
Question 13, and go to Question 14. Question 13 must then be coded as “M Missing/Don't know.” Coding may be done automatically by the telephone
interviewing system or later during data preparation.

1

HCAHPS Survey Questions:
•
•
•
•

The phone introduction script and HCAHPS questions must be read verbatim
It is optional to include the day of the week, e.g., Monday, with the discharge date
(mm/dd/yyyy)
All text that appears in lowercase letters must be read out loud
Text in UPPERCASE letters must not be read out loud
o However, YES and NO response categories are to be read if necessary

Supplemental Items:
•
•
•

The [NUMBER] of minutes to answer the HCAHPS Survey questions 1-32 should equal
“8”
If hospital-specific supplemental question(s) are added, the mandatory transition statement
must be read immediately before the supplemental question(s)
If hospital-specific supplemental items (limit of 12) are added, the [NUMBER] of minutes
should be populated as follows:
o If 1 to 5 supplemental items are added, “[NUMBER]” should equal “9”
o If 6 to 9 supplemental items are added, “[NUMBER]” should equal “10”
o If 10 to 12 supplemental items are added, “[NUMBER]” should equal “11”
Note: See Phone Only Survey Administration Chapter for all guidelines on the use of
supplemental items.

Proxy Respondents:
•

•
•

In the event that a sampled patient is unable to begin or complete the interview themselves,
the interview may be conducted with a proxy if the following conditions apply:
o The sampled patient proactively requests that a proxy answer the survey
o The interviewer determines the patient is struggling during the interview and asks
the patient if they want someone to help them complete the survey
o The interviewer obtains permission from the patient to interview the proxy
o The proxy agrees to complete the HCAHPS Survey on behalf of the patient
 either during the current call attempt
 or at another time as designated by the proxy
• The patient need not be present when the interview with the proxy is
conducted
If the interviewer is unable to speak to the patient directly in order to identify a proxy
respondent and obtain the patient’s permission to do the interview for them, the interviewer
must not proceed with the interview
A script is included for identifying a proxy respondent, as well as a reminder for the proxy
respondent to answer the survey questions about the patient

See Appendix W Interviewing Guidelines for further phone interviewing techniques and
guidance, including refusal avoidance and probing.

2

INITIATING CONTACT
START

Hello, may I please speak to [SAMPLED PATIENT NAME]?
OPTIONAL START:
Hello, my name is [INTERVIEWER NAME], may I please speak to [SAMPLED
PATIENT NAME]?
<1>
<2>
<3>

YES [GO TO INTRO]
NO [REFUSAL]
NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]

IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [DATA COLLECTION
CONTRACTOR] on behalf of [HOSPITAL NAME]. We are conducting a survey
about healthcare. Is [SAMPLED PATIENT NAME] available?
IF ASKED WHETHER PERSON CAN SERVE AS PROXY FOR SAMPLED
PATIENT:
Yes, but I need to speak with [SAMPLED PATIENT NAME] to obtain their
permission.
IF THE SAMPLED PATIENT IS NOT AVAILABLE:
Can you tell me a convenient time to call back to speak with them?
IF THE SAMPLED PATIENT SAYS THIS IS NOT A GOOD TIME:
If you don’t have the time now, when is a more convenient time to call you back?
IF ASKED IF YOU WOULD LIKE TO SPEAK TO “SR.” OR “JR.”:
I would like to speak with [PATIENT NAME] who is approximately [AGE
RANGE]. Is that person available?
IF SOMEONE OTHER THAN THE SAMPLED PATIENT ANSWERS THE PHONE
RECONFIRM THAT YOU ARE SPEAKING WITH THE SAMPLED PATIENT WHEN THEY
PICK UP.

3

SPEAKING WITH SAMPLED PATIENT
INTRO

Hello, this is [INTERVIEWER NAME], calling (OPTIONAL TO STATE from
[DATA COLLECTION CONTRACTOR]) on behalf of [HOSPITAL NAME].
[HOSPITAL NAME] is participating in a survey about the care people receive in
the hospital. Your responses will help improve the quality of hospital care and help
other people make more informed choices about their care.
Participation in the survey is completely voluntary and your answers will be kept
private. It should take about [NUMBER] minutes to complete. [SURVEY
VENDOR/HOSPITAL TO SPECIFY NUMBER – SEE PROGRAMMING
INSTRUCTIONS]
This call may be monitored (OPTIONAL TO STATE and/or recorded) for quality
improvement purposes.
OPTIONAL QUESTION TO INCLUDE:
I’d like to begin the survey now, is this a good time for us to continue?
<1>
<2>
<3>
<4>
<5>

SPEAKING WITH SAMPLED PATIENT [GO TO S1]
[REFUSAL]
NOT AVAILABLE RIGHT NOW [SET CALLBACK]
PATIENT NEEDS HELP WITH THE SURVEY [GO TO PROXY1]
PATIENT INDICATES PROXY BY NAME OR RELATIONSHIP [GO
TO PROXY2]

IF IT BECOMES CLEAR THAT THE PATIENT IS MENTALLY OR PHYSICALLY
INCAPACITATED AND CANNOT COMPLETE THE PHONE INTERVIEW THEMSELF OR
REQUIRES ASSISTANCE IN COMPLETING THE INTERVIEW, ONLY THE PATIENT CAN
GIVE PERMISSION FOR A PROXY TO COMPLETE THE SURVEY. SELECT OPTION 4/GO
TO PROXY1.

4

CONFIRMING USE OF PROXY
PROXY1

If you need help in completing this survey, you can have someone help you or do
the survey for you. This person should be able to accurately answer questions about
this hospital stay.
Is there someone who could help you answer the survey, or who could do the survey
for you?
<1>
<2>

PROXY2

PATIENT WANTS HELP TO RESPOND OR PROXY TO ANSWER
SURVEY ON BEHALF OF PATIENT [GO TO PROXY2]
NO [REFUSAL]

What is the name of the person who can help you? [COLLECT NAME OF THE
PROXY AND PHONE NUMBER, IF NECESSARY]
:
Is that person available to come to the phone now?
<1>
<2>

YES [GO TO PROXY_INTRO]
NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK TO PROXY]
SPEAKING WITH PROXY

PROXY_INTRO
Hello, this is [INTERVIEWER NAME], calling (optional to state from [DATA
COLLECTION CONTRACTOR]) on behalf of [HOSPITAL NAME].
[HOSPITAL NAME] is participating in a survey about the care people receive in
the hospital. [SAMPLED PATIENT NAME] has given permission for you to
answer this interview on their behalf. Your responses will help improve the quality
of hospital care and help other people make more informed choices about their care.
Participation in the survey is completely voluntary and your answers will be kept
private. It should take about [NUMBER] minutes to complete. [SURVEY
VENDOR/HOSPITAL TO SPECIFY NUMBER – SEE PROGRAMMING
INSTRUCTIONS]
This call may be monitored (OPTIONAL TO STATE and/or recorded) for quality
improvement purposes.
OPTIONAL QUESTION TO INCLUDE:
I’d like to begin the survey now, is this a good time for us to continue?
<1>
<2>
<3>

SPEAKING WITH PROXY [GO TO S1]
[REFUSAL]
NOT AVAILABLE RIGHT NOW [SET CALLBACK TO PROXY]

5

CALL BACK TO COMPLETE A SURVEY PREVIOUSLY STARTED WITH THE
SAMPLED PATIENT/PROXY
RESUME

Hello, may I please speak to [SAMPLED PATIENT/PROXY NAME]?
OPTIONAL START:
Hello, my name is [INTERVIEWER NAME], may I please speak to [SAMPLED
PATIENT/PROXY NAME]?
<1>
<2>
<3>

YES [GO TO CONFIRM PATIENT/GO TO CONFIRM PROXY]
NO [REFUSAL]
NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]

IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [DATA COLLECTION
CONTRACTOR] on behalf of [HOSPITAL NAME]. Is [SAMPLED
PATIENT/PROXY NAME] available to complete a survey that they started at an
earlier date?
CONFIRM PATIENT/PROXY FOR A PREVIOUSLY STARTED SURVEY:
This is [INTERVIEWER NAME] calling from [DATA COLLECTION
CONTRACTOR] on behalf of [HOSPITAL NAME]. I would like to confirm that
I am speaking with [SAMPLED PATIENT/PROXY NAME]. I am calling to
continue the survey started on an earlier date. CONTINUE SURVEY WHERE
PREVIOUSLY LEFT OFF.
CONFIRM PATIENT/PROXY FOR A CALL BACK:
This is [INTERVIEWER NAME] calling from [DATA COLLECTION
CONTRACTOR] on behalf of [HOSPITAL NAME]. I would like to confirm that
I am speaking with [SAMPLED PATIENT/PROXY NAME]. I am calling back at
the time you requested to take the survey.

6

CONFIRMING DISCHARGE DATE
S1

IF SPEAKING WITH SAMPLED PATIENT:
Our records show that you were discharged from [HOSPITAL NAME] on or about
[DISCHARGE DATE (mm/dd/yyyy)]. Is that right?
IF SPEAKING WITH PROXY:
Our records show that [SAMPLED PATIENT NAME] was discharged from
[HOSPITAL NAME] on or about [DISCHARGE DATE (mm/dd/yyyy)]. Is that
right?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
<1>
<2>
<3>
<4>

YES [GO TO Q1_INTRO]
NO [GO TO INEL1]
DON’T KNOW [GO TO INEL1]
REFUSAL [GO TO INEL1]
CONFIRMING INELIGIBLE PATIENTS

INEL1

IF SPEAKING WITH SAMPLED PATIENT:
Were you ever at this hospital?
IF SPEAKING WITH PROXY:
Was [SAMPLED PATIENT NAME] ever at this hospital?
<1>
<2>

INEL2

YES [GO TO INEL2]
NO [GO TO INEL_END]

IF SPEAKING WITH SAMPLED PATIENT:
Were you a patient at this hospital in the last year?
IF SPEAKING WITH PROXY:
Was [SAMPLED PATIENT NAME] a patient at this hospital in the last year?
<1>
<2>

INEL3

YES [GO TO INEL3]
NO [GO TO INEL_END]

When was this?
IF ANY DATE WAS WITHIN TWO WEEKS OF [DISCHARGE DATE
(mm/dd/yyyy)], GO TO Q1_INTRO; OTHERWISE, GO TO INEL_END.

INEL_END

Thank you for your time. It looks like we made a mistake. Have a good
(day/evening).

7

BEGIN HCAHPS QUESTIONS
Q1_INTRO

IF SPEAKING WITH SAMPLED PATIENT:
Please answer the questions in this survey about this stay at [HOSPITAL NAME].
When thinking about your answers, do not include any other hospital stays. The
first questions are about the care you received from nurses during this hospital stay.
IF SPEAKING WITH PROXY:
As you answer the questions in this interview, please remember that you are
answering the questions for [SAMPLED PATIENT NAME] and their stay at
[HOSPITAL NAME]. When thinking about your answers, do not include any other
hospital stays. The first questions are about the care received from nurses during
this hospital stay.
BE PREPARED TO PROBE IF THE PATIENT OR PROXY ANSWERS
OUTSIDE OF THE ANSWER CATEGORIES PROVIDED. PROBE BY
REPEATING THE ANSWER CATEGORIES ONLY; DO NOT
INTERPRET FOR THE PATIENT OR PROXY.

Q1

During this hospital stay, how often did nurses treat you with courtesy and respect?
Would you say…
<1>
<2>
<3>
<4>

Never,
Sometimes,
Usually, or
Always?

MISSING/DK
Q2

During this hospital stay, how often did nurses listen carefully to you? Would you
say…
<1>
<2>
<3>
<4>

Never,
Sometimes,
Usually, or
Always?

MISSING/DK

8

Q3

During this hospital stay, how often did nurses explain things in a way you could
understand? Would you say…
<1>
<2>
<3>
<4>

Never,
Sometimes,
Usually, or
Always?

MISSING/DK
Q4_INTRO

The next questions are about the care you received from doctors during this hospital
stay.

Q4

During this hospital stay, how often did doctors treat you with courtesy and respect?
Would you say…
<1>
<2>
<3>
<4>

Never,
Sometimes,
Usually, or
Always?

MISSING/DK
Q5

During this hospital stay, how often did doctors listen carefully to you? Would you
say…
<1>
<2>
<3>
<4>

Never,
Sometimes,
Usually, or
Always?

MISSING/DK
Q6

During this hospital stay, how often did doctors explain things in a way you could
understand? Would you say…
<1>
<2>
<3>
<4>

Never,
Sometimes,
Usually, or
Always?

MISSING/DK

9

Q7_INTRO

The next set of questions is about the hospital environment.

Q7

During this hospital stay, how often were your room and bathroom kept clean?
Would you say…
<1>
<2>
<3>
<4>

Never,
Sometimes,
Usually, or
Always?

MISSING/DK
Q8

During this hospital stay, how often were you able to get the rest you needed?
Would you say…
<1>
<2>
<3>
<4>

Never,
Sometimes,
Usually, or
Always?

MISSING/DK
Q9

During this hospital stay, how often was the area around your room quiet at night?
Would you say…
<1>
<2>
<3>
<4>

Never,
Sometimes,
Usually, or
Always?

MISSING/DK
Q10_INTRO The next questions are about your care in this hospital.
Q10

During this hospital stay, how often were doctors, nurses and other hospital staff
informed and up-to-date about your care? Would you say…
<1>
<2>
<3>
<4>

Never,
Sometimes,
Usually, or
Always?

MISSING/DK

10

Q11

During this hospital stay, how often did doctors, nurses and other hospital staff
work well together to care for you? Would you say…
<1>
<2>
<3>
<4>

Never,
Sometimes,
Usually, or
Always?

MISSING/DK
Q12

During this hospital stay, did you need help from nurses or other hospital staff in
getting to the bathroom or in using a bedpan?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
<1>
<2>

YES
NO [GO TO Q14]

MISSING/DK [GO TO Q14]
Q13

How often did you get help in getting to the bathroom or in using a bedpan as soon
as you wanted? Would you say…
<1>
<2>
<3>
<4>

Never,
Sometimes,
Usually, or
Always?

[<8> NOT APPLICABLE]
MISSING/DK
[NOTE: IF Q12 = “2 - NO” THEN Q13 = “8 - NOT APPLICABLE” OR IF Q12 =
“M - MISSING/DK” THEN Q13 = “MISSING/DK”]
Q14

During this hospital stay, when you asked for help right away, how often did you
get help as soon as you needed? Would you say…
<1>
<2>
<3>
<4>
<9>

Never,
Sometimes,
Usually,
Always, or
I never asked for help right away?

MISSING/DK

11

Q15

During this hospital stay, were you given any medicine that you had not taken
before?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
<1>
<2>

YES
NO [GO TO Q18]

MISSING/DK [GO TO Q18]
Q16

Before giving you any new medicine, how often did hospital staff tell you what the
medicine was for? Would you say…
<1>
<2>
<3>
<4>

Never,
Sometimes,
Usually, or
Always?

[<8> NOT APPLICABLE]
MISSING/DK
[NOTE: IF Q15 = “2 - NO” THEN Q16 = “8 - NOT APPLICABLE” OR IF Q15 =
“M - MISSING/DK” THEN Q16 = “M - MISSING/DK”]
Q17

Before giving you any new medicine, how often did hospital staff describe possible
side effects in a way you could understand? Would you say…
<1>
<2>
<3>
<4>

Never,
Sometimes,
Usually, or
Always?

[<8> NOT APPLICABLE]
MISSING/DK
[NOTE: IF Q15 = “2 - NO” THEN Q17 = “8 - NOT APPLICABLE” OR IF Q15 =
“M - MISSING/DK” THEN Q17 = “M - MISSING/DK”]
Q18

During this hospital stay, did doctors, nurses and other hospital staff help you to
rest and recover? Would you say…
<1>
<2>
<3>

Yes, definitely,
Yes, somewhat, or
No?

MISSING/DK

12

Q19_INTRO The next questions are about when you left the hospital.
Q19

Did doctors, nurses or other hospital staff work with you and your family or
caregiver in making plans for your care after you left the hospital? Would you say…
<1>
<2>
<3>

Yes, definitely,
Yes, somewhat, or
No?

MISSING/DK
Q20

Did doctors, nurses or other hospital staff give your family or caregiver enough
information about what symptoms or health problems to watch for after you left the
hospital? Would you say…
<1>
<2>
<3>
<9>

Yes, definitely,
Yes, somewhat,
No, or
I did not have family or a caregiver watch for symptoms or health
problems?

MISSING/DK
Q21

When you left the hospital, did you go directly to your own home, to someone else’s
home, or to another health facility?
READ RESPONSE CHOICES 1, 2 AND 3 ONLY IF NECESSARY
<1>
<2>
<3>

OWN HOME
SOMEONE ELSE’S HOME
ANOTHER HEALTH FACILITY [GO TO Q24]

MISSING/DK [GO TO Q24]
Q22

During this hospital stay, did doctors, nurses, or other hospital staff talk with you
about whether you would have the help you needed after you left the hospital?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
<1>
<2>

YES
NO

[<8> NOT APPLICABLE]
MISSING/DK
[NOTE: IF Q21 = “3 - ANOTHER HEALTH FACILITY” THEN Q22 = “8 - NOT
APPLICABLE” IF Q21 = “M - MISSING/DK” THEN Q22 = “M - MISSING/DK”]

13

Q23

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?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY
<1>
<2>

YES
NO

[<8> NOT APPLICABLE]
MISSING/DK
[NOTE: IF Q21 = “3 - ANOTHER HEALTH FACILITY” THEN Q23 = “8 - NOT
APPLICABLE” IF Q21 = “M - MISSING/DK” THEN Q23 = “M - MISSING/DK”]
Q24

We want to know your overall rating of your stay at [HOSPITAL NAME]. This is
the stay that ended around [DISCHARGE DATE (mm/dd/yyyy)]. Please do not
include any other hospital stays in your answer.
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?
IF THE PATIENT DOES NOT PROVIDE AN APPROPRIATE RESPONSE,
PROBE BY REPEATING: “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>
<2>
<3>
<4>
<5>
<6>
<7>
<8>
<9>
<10>

0
1
2
3
4
5
6
7
8
9
10

MISSING/DK

14

Q25

Would you recommend this hospital to your friends and family? Would you say…
<1>
<2>
<3>
<4>

Definitely no,
Probably no,
Probably yes, or
Definitely yes?

MISSING/DK
Q26_INTRO This next set of questions is about you. (IF SPEAKING WITH PROXY: Please
keep in mind that you are answering the questions on behalf of the patient.)
Q26

Was this hospital stay planned in advance? Would you say…
<1>
<2>
<3>

Yes, definitely,
Yes, somewhat, or
No?

MISSING/DK
Q27

In general, how would you rate your overall health? Would you say that it is…
<1>
<2>
<3>
<4>
<5>

Excellent,
Very good,
Good,
Fair, or
Poor?

MISSING/DK
Q28

In general, how would you rate your overall mental or emotional health? Would
you say that it is…
<1>
<2>
<3>
<4>
<5>

Excellent,
Very good,
Good,
Fair, or
Poor?

MISSING/DK

15

Q29

What language do you mainly speak at home?
READ RESPONSE CHOICES IF NECESSARY AND STOP WHEN PATIENT
PROVIDES A RESPONSE: Would you say that you mainly speak…
<1>
<2>
<3>
<20>

English,
Spanish,
Chinese, or
Another language?

MISSING/DK [GO TO END]
IF THE PATIENT REPLIES WITH MULTIPLE LANGUAGES, PROBE:
Would you say that you mainly speak [LANGUAGE A] or [LANGUAGE B]?
IF THE PATIENT REPLIES THAT THEY SPEAK AMERICAN CODE AS 1 –
ENGLISH.
Q30

What is the highest grade or level of school that you have completed? Please
listen to all six response choices before you answer. Did you…
<1>
<2>
<3>
<4>
<5>
<6>

Complete the 8th grade or less,
Complete some high school, but did not graduate,
Graduate from high school or earn a GED,
Complete some college or earn a 2-year degree,
Graduate from a 4-year college, or
Complete more than a 4-year college degree?

MISSING/DK
ACADEMIC TRAINING BEYOND A HIGH SCHOOL DIPLOMA THAT DOES
NOT LEAD TO A BACHELOR’S DEGREE SHOULD BE CODED AS 4. IF THE
PATIENT DESCRIBES NON-ACADEMIC TRAINING, SUCH AS TRADE
SCHOOL, PROBE TO FIND OUT IF THEY HAVE A HIGH SCHOOL
DIPLOMA AND CODE 2 OR 3, AS APPROPRIATE.

16

Q31

Are you of Spanish, Hispanic or Latino origin?
READ YES/NO RESPONSE CHOICES ONLY IF NECESSARY

<1>

YES
NO

MISSING/DK
IF YES: Would you say you are… (READ ALL RESPONSE CHOICES)
<2>
<3>
<4>
<5>

Cuban,
Mexican, Mexican American, Chicano,
Puerto Rican, or
Other Spanish/Hispanic/Latino?

MISSING/DK
[FOR PHONE INTERVIEWING, QUESTION 32 IS BROKEN INTO PARTS A-E]
READ ALL RACE CATEGORIES, PAUSING AT EACH RACE CATEGORY TO ALLOW
PATIENT TO REPLY TO EACH RACE CATEGORY.
IF THE PATIENT REPLIES, “WHY ARE YOU ASKING MY RACE?”:
We ask about your race for demographic purposes. We want to be sure that the people we survey
accurately represent the racial diversity in this country.
IF THE PATIENT REPLIES, “I ALREADY TOLD YOU MY RACE”:
I understand, however the survey requires me to ask about all races so results can include people
who are multiracial. If the race does not apply to you please answer “No.” Thanks for your
patience.
Q32

When I read the following, please tell me if the category describes your race. I am
required to read all five categories. Please answer “Yes” or “No” to each of the
categories.

Q32A

Are you American Indian or Alaska Native?
<1>
<0>

YES/AMERICAN INDIAN OR ALASKA NATIVE
NO/NOT AMERICAN INDIAN OR ALASKA NATIVE

MISSING/DK

17

Q32B

Are you Asian?
<1>
<0>

YES/ASIAN
NO/NOT ASIAN

MISSING/DK
Q32C

Are you Black or African American?
<1>
<0>

YES/BLACK OR AFRICAN AMERICAN
NO/NOT BLACK OR AFRICAN AMERICAN

MISSING/DK
Q32D

Are you Native Hawaiian or other Pacific Islander?
<1>
<0>

YES/NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
NO/NOT NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER

MISSING/DK
Q32E

Are you White?
<1>
<0>

YES/WHITE
NO/NOT WHITE

MISSING/DK
IF THE PATIENT REPLIES THAT THEY ARE CAUCASIAN CODE AS
WHITE.
[NOTE: IF HOSPITAL-SPECIFIC SUPPLEMENTAL QUESTION(S) ARE ADDED, LIMIT OF
12, THE MANDATORY TRANSITION STATEMENT MUST BE READ IMMEDIATELY
BEFORE THE SUPPLEMENTAL QUESTION(S).]
Questions 1-32 in this survey are from the U.S. Department of Health and Human
Services or HHS, for use in quality measurement. Any additional questions are
from [NAME OF HOSPITAL] to get more feedback about your hospital stay and
will not be shared with HHS.
END

Those are all the questions I have. Thank you for your time. Have a good
(day/evening).

18