Home and Community-Based Services (HCBS) Experience Survey

[STATE LOGO OR LETTERHEAD]

DATE

FIRST AND LAST NAME
LINE ONE OF ADDRESS
LINE TWO OF ADDRESS (IF ANY)
CITY, STATE   ZIP

Dear {Mr./Ms.} [LAST NAME]:

We would like your help.

This letter is to let you know that someone from SURVEY VENDOR may call you in the next few weeks, asking you to answer questions about the people paid to help you and the services and supports you get from HCBS PROGRAM NAME.

SURVEY VENDOR is working with Truven Health Analytics, a company that does health care studies, to test a questionnaire about people’s experience with the HCBS PROGRAM NAME. If you say yes, SURVEY VENDOR will either ask you these questions over the phone, or at your home or another place you choose. Your answers will help STATE find ways to improve the HCBS PROGRAM NAME.

The Centers for Medicare & Medicaid Services and STATE are sponsoring this study. By answering the questions in the questionnaire, you will also help make the questionnaire better.

You have been chosen at random from a list of all people in HCBS PROGRAM NAME. You have not been picked for any other reason. We hope you will say yes to answering the questions if you are called.

If you decide to participate, what you have to say will be private. Your individual answers will not be shared with STATE or any of the people who provide you services. SURVEY VENDOR will be combining your answers with the answers from other people and reporting them all together, so no one will see your individual answers.

It is your choice whether to answer the questions or not.  If you decide not to, that won’t change any of the services you get from HCBS PROGRAM NAME.

If you have any questions about the study, please call SURVEY VENDOR at xxx-xxx-xxx. You can also call STATE CONTACT NUMBER. More information about this study is provided in the attached consent form.

Thank you in advance for your help!

Sincerely,

SIGNATURE OF STATE OFFICIAL