Survey Instructions
This survey is about your experiences with dialysis care at [SAMPLE FACILITY NAME].
Answer each question by marking 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 25
Where do you get your dialysis treatments?
0
At
home or at a skilled nursing home where I live If At home or
at a skilled nursing home where I live, Go to Question 45
0 At the dialysis center
0
I do not currently receive
dialysis
If
I do not currently receive dialysis, Go to Question 45
How long have you been getting dialysis at [SAMPLE FACILITY
NAME]?
Less than 3 months
If
Less than 3 months, Go to Question 45
At least 3 months but less than 1 year
At least 1 year but less than
5 years
0 5 years or more
5 I do not currently receive dialysis at this dialysis center
If I do not currently receive dialysis at this dialysis center, Go to Question 45
Your kidney doctors are the doctor or doctors most involved in your dialysis care now. This includes kidney doctors that you see inside and outside the center.
In the last 3 months, how often did your kidney doctors listen carefully to you?
Never
Sometimes
Usually
Always
In the last 3 months, how often did your kidney doctors explain things in a way that was easy for you to understand?
Never
Sometimes
Usually
Always
In the last 3 months, how often did your kidney doctors show respect for what you had to say?
Never
Sometimes
Usually
Always
In the last 3 months, how often did your kidney doctors spend enough time with you?
In the last 3 months, how often
did you feel your kidney doctors really cared about you as a person?
0 Never
0 Sometimes
Usually
Always
Using any number from 0 to 10, where 0 is the worst kidney doctors possible and 10 is the best kidney doctors possible, what number would you use to rate the kidney doctors you have now?
0 Worst kidney doctors possible
1
0 2
0 3
5
6
7
8
9
00 10 Best kidney doctors possible
Do your kidney doctors seem informed and up-to-date about the health care you receive from other doctors?
For the next questions, dialysis center staff does not include doctors. Dialysis center staff means nurses, technicians, dietitians, and social workers at this dialysis center.
In the last 3 months, how often did the dialysis center staff listen carefully to you?
1 Never
0 Sometimes
0 Usually
In the last 3 months, how often did the dialysis center staff explain things in a way that was easy for you to understand?
In the last 3 months, how often did you feel the dialysis center staff really cared about you as a person?
0 Never
0
Sometimes
Usually
Always
In the last 3 months, how often did dialysis center staff make you as comfortable as possible during dialysis?
0 Never
0 Sometimes
Usually
In the last 3 months, did dialysis center staff keep information about you and your health as private as possible from other patients?
0 Yes
0 No
In the last 3 months, did you feel comfortable asking the dialysis center staff everything you wanted about dialysis care?
The dialysis center staff can connect you to the dialysis machine through a graft, fistula, or catheter. Do you know how to take care of your graft, fistula, or catheter?
Yes
No
In the last 3 months, which one did they use most often to connect you to the dialysis machine?
Graft
Fistula
0
Catheter
If
Catheter, Go to
Question 22
0
I don’t know
If
Don’t
Know, Go to Question 22
In the last 3 months, how often did dialysis center staff insert your needles with as little pain as possible?
Never
Sometimes
Usually
In the last 3 months, did any problems occur during your dialysis?
0 Yes
0 No If No, Go to Question 25
In the last 3 months, how often was the dialysis center staff able to manage problems during your dialysis?
0 Never
0
Sometimes
Usually
Always
In the last 3 months, how often did dialysis center staff behave in a professional manner?
0 Never
0 Sometimes
Usually
Always
Please remember that for these questions, dialysis center staff does not include doctors. Dialysis center staff means nurses, technicians, dietitians, and social workers at this dialysis center.
In the last 3 months, did dialysis center staff talk to you about what you should eat and drink?
In the last 3 months, how often did dialysis center staff explain blood test results in a way that was easy to understand?
Never
Sometimes
Usually
Always
As a patient you have certain rights. For example, you have the right to be treated with respect and the right to privacy. Did this dialysis center ever give you any written information about your rights as a patient?
Yes
No
Did dialysis center staff at this center ever review your rights as a patient with you?
Yes
No
Has dialysis center staff ever told you what to do if you experience a health problem at home?
32. Using any number from 0 to 10, where 0 is the worst dialysis center staff possible and 10 is the best dialysis center staff possible, what number would you use to rate your dialysis center staff?
0 0 Worst dialysis center staff possible
0 1
0 2
0 3
0
4
5
6
7
8
9
00 10 Best dialysis center staff possible
33. In the last 3 months, when you arrived on time, how often did you get put on the dialysis machine within 15 minutes of your appointment or shift time?
35. Using any number from 0 to 10, where 0 is the worst dialysis center possible and 10 is the best dialysis center possible, what number would you use to rate this dialysis center?
0 Worst dialysis center possible
1
0 2
0 3
0 4
5
6
7
8
9
000 10 Best dialysis center possible
The next few questions ask about your care in the last 12 months. As you answer these questions, think only about your experience at [SAMPLE FACILITY NAME], even if you have not been receiving care there for the entire 12 months.
You can treat kidney disease with dialysis at a center, a kidney transplant, or with dialysis at home. In the last 12 months, did your kidney doctors or dialysis center staff talk to you as much as you wanted about which treatment is right for you?
Are you eligible for a kidney transplant?
0
Yes
If
Yes, Go to Question 39
0
No
3
I don’t know
If
Don’t
Know, Go to Question 39
In the last 12 months, has a doctor or dialysis center staff explained to you why you are not eligible for a kidney transplant?
0 Yes
0 No
Peritoneal dialysis is dialysis given through the belly and is usually done at home. In the last 12 months, did either your kidney doctors or dialysis center staff talk to you about peritoneal dialysis?
Yes
No
In the last 12 months, were you as involved as much as you wanted in choosing the treatment for kidney disease that is right for you?
In general, how would you rate your overall mental or emotional health?
Excellent
Very good
Good
Fair
Poor
Are you being treated for high blood pressure?
Yes
No
Are you being treated for diabetes or high blood sugar?
Yes
No
Are you being treated for heart disease or heart problems?
Yes
No
Are you deaf or do you have serious difficulty hearing?
Yes
No
Are you blind or do you have serious difficulty seeing, even when wearing glasses?
Yes
No
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?
Yes
No
Do you have serious difficulty walking or climbing stairs?
Yes
No
Do you have difficulty dressing or bathing?
Yes
No
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone, such as visiting a doctor’s office or shopping?
Yes
No
What is the highest grade or level of school that you have completed?
No formal education
5th grade or less
6th, 7th, or 8th grade
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
What language do you mainly speak at home?
English
Spanish 3 Chinese 4 Samoan
Russian
Vietnamese
Portuguese
Some other language (please identify):
_______________________
Are you of Spanish, Hispanic, or Latino origin or descent?
No, not Spanish/Hispanic/Latino
Yes, Puerto Rican
Yes, Mexican, Mexican American,
Chicano
Yes, Cuban
Yes, other Spanish/Hispanic/ Latino
What is your race? (One or more categories may be selected.)
American Indian or Alaska Native
2
Asian – Please Specify
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Black or African American
Native Hawaiian or Pacific
Islander – Please Specify
Guamanian or Chamorro
Native Hawaiian
Samoan
Other Pacific Islander
White
Did someone help you complete this survey?
Yes
No Thank you. Please return the completed survey in the postage-paid envelope.
Who helped you complete this survey?
A family member
A friend
A staff member at the dialysis center
Someone else (please print):
________________________
How did that person help you? Check all that apply.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way (please print):
________________________
Thank you. Please return the survey in the enclosed envelope to:
VENDOR’S NAME
STREET ADDRESS 1
STREET ADDRESS 2 CITY, STATE, ZIP
0
Never
0 Sometimes
0 Usually
0 Always
0 Yes
0 No
0
Sometimes
0 Usually
0 Always
0 . In the last 3 months, how often did the dialysis center staff show respect for what you had to say?
0 Never
0 Sometimes
0 Usually
0 Always
0 . In the last 3 months, how often did the dialysis center staff spend enough time with you?
0 Never
0 Sometimes
0 Usually
0 Always
0 Yes
0 No
18. In the last 3 months, has anyone on the dialysis center staff asked you about how your kidney disease affects other parts of your life?
0 Yes
0 No
0 Always
0 I insert my own needles
22. In the last 3 months, how often did dialysis center staff check you as closely as you wanted while you were on the dialysis machine?
0 Never
0 Sometimes
0 Usually
0 Always
0 Yes
0 No
0
Yes
0 No
31. Has any dialysis center staff ever told you how to get off the machine if there is an emergency at the center?
0 Yes
0 No
0
Never
0 Sometimes
0 Usually
0 Always
34. In the last 3 months, how often was the dialysis center as clean as it could be?
0 Never
0 Sometimes
0 Usually
0 Always
0 Yes
0 No
0
Yes
0 No
41. In the last 12 months, were you ever unhappy with the care you received at the dialysis center or from your kidney doctors?
0 Yes
0 No If No, Go to
Question 45
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File Modified | 0000-00-00 |
File Created | 0000-00-00 |