Form 0920-0953 Queens2018update

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very
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1
NURSE/ASSISTANT/TECHNICIAN/NON-MD STAFF
1. Friendliness/courtesy of the nurse/assistant ................................................................
2. Concern the nurse/assistant showed for your problem ................................................

2

3

4

5

Comments (describe good or bad experience):

CLINICIAN & GROUP CAHPS® SURVEY

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1. Friendliness/courtesy of the care provider ....................................................................
Explanations the care provider gave you about your problem or condition..................
Concern the care provider showed for your questions or worries ................................
Care provider's efforts to include you in decisions about your treatment .....................
Information the care provider gave you about medications (if any)..............................
Instructions the care provider gave you about follow-up care (if any) ..........................
Degree to which care provider talked with you using words you could understand .....
Amount of time the care provider spent with you..........................................................
Your confidence in this care provider............................................................................
Likelihood of your recommending this care provider to others.....................................

1.
2.
3.
4.

The questions in this survey will refer to the provider
named in Question 1 as "this provider." Please think
of that person as you answer the survey.

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How well staff protected your safety (by washing hands, wearing gloves, etc.) ...........
Our sensitivity to your needs .........................................................................................
Our concern for your privacy.........................................................................................
Cleanliness of our practice............................................................................................

Comments (describe good or bad experience):
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OVERALL ASSESSMENT

1. How well the staff worked together to care for you .......................................................
2. Likelihood of your recommending our practice to others..............................................

(optional)

Telephone Number:

2. Is this the provider you usually see if you need a
check-up, want advice about a health problem, or
get sick or hurt?
Yes
No
3. How long have you been going to this provider?
Less than 6 months
At least 6 months but less than 1 year
At least 1 year but less than 3 years
At least 3 years but less than 5 years
5 years or more
YOUR CARE FROM THIS PROVIDER
IN THE LAST 12 MONTHS

Comments (describe good or bad experience):

Patient's Name:

YOUR PROVIDER
1. Our records show that you got care from the
provider named below.
Is that right?
Yes
No  If No, go to #29

Comments (describe good or bad experience):
PERSONAL ISSUES

SURVEY INSTRUCTIONS: Answer each question 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:
Yes  If Yes, go to #1
Please use black or blue ink to
No
fill in the circle completely.
Please rate your visit on:
Example:

(optional)

Thank you! Please return the completed survey in the postage-paid envelope.
Return to: Survey Processing, 710 Rush Street, South Bend, IN 46601
Public reporting burden of this collection of information is estimated to average 4 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not
conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to - CDC/
ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0953).

© 2010 PRESS GANEY ASSOCIATES, INC.,
All Rights Reserved
CL#12062-MD0130-02-10/14

These questions ask about your own health care.
Do not include care you got when you stayed
overnight in a hospital. Do not include the times
you went for dental care visits.
4. In the last 12 months, how many times did you
visit this provider to get care for yourself?
None  If None, go to #29
1 time
2
3
4
5 to 9
10 or more times
5. In the last 12 months, did you phone this provider's
office to get an appointment for an illness, injury, or
condition that needed care right away?
Yes
No  If No, go to #7

6. In the last 12 months, when you phoned this
provider's office to get an appointment for care
you needed right away, how often did you get an
appointment as soon as you needed?
Never
Sometimes
Usually
Always
7. In the last 12 months, did you make any
appointments for a check-up or routine care
with this provider?
Yes
No  If No, go to #9
8. In the last 12 months, when you made an
appointment for a check-up or routine care with
this provider, how often did you get an appointment
as soon as you needed?
Never
Sometimes
Usually
Always
9. In the last 12 months, did you phone this provider's
office with a medical question during regular
office hours?
Yes
No  If No, go to #11
10. In the last 12 months, when you phoned this
provider's office during regular office hours, how
often did you get an answer to your medical
question that same day?
Never
Sometimes
Usually
Always
11. In the last 12 months, did you phone this
provider's office with a medical question after
regular office hours?
Yes
No  If No, go to #13
continued...

Draft

CARE PROVIDER
DURING YOUR VISIT, YOUR CARE WAS PROVIDED PRIMARILY BY A DOCTOR, PHYSICIAN ASSISTANT
(PA), NURSE PRACTITIONER (NP), OR MIDWIFE. PLEASE ANSWER THE FOLLOWING QUESTIONS
WITH THAT HEALTH CARE PROVIDER IN MIND.
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2.
3.
4.
5.
6.
7.
8.
9.
10.

Formed Approved
OMB No. 0920-0953
Exp. Date 07/31/2018

12. In the last 12 months, when you phoned this
provider's office after regular office hours, how
often did you get an answer to your medical
question as soon as you needed?
Never
Sometimes
Usually
Always
13. Wait time includes time spent in the waiting room
and exam room. In the last 12 months, how often
did you see this provider within 15 minutes of
your appointment time?
Never
Sometimes
Usually
Always
YOUR CARE FROM THIS PROVIDER
DURING YOUR MOST RECENT VISIT
These questions ask about your most recent visit
with this provider. Please answer only for your own
health care.
14. How long has it been since your most recent visit
with this provider?
Less than 1 month
At least 1 month but less than 3 months
At least 3 months but less than 6 months
At least 6 months but less than 12 months
12 months or more
15. Wait time includes time spent in the waiting room
and exam room. During your most recent visit,
did you see this provider within 15 minutes of
your appointment time?
Yes
No

19. During your most recent visit, did this provider give
you easy to understand information about these
health questions or concerns?
Yes, definitely
Yes, somewhat
No
20. During your most recent visit, did this provider
seem to know the important information about
your medical history?
Yes, definitely
Yes, somewhat
No
21. During your most recent visit, did this provider
show respect for what you had to say?
Yes, definitely
Yes, somewhat
No
22. During your most recent visit, did this provider
spend enough time with you?
Yes, definitely
Yes, somewhat
No
23. During your most recent visit, did this provider
order a blood test, x-ray, or other test for you?
Yes
No  If No, go to #25
24. Did someone from this provider's office follow up
to give you those results?
Yes
No

CLERKS AND RECEPTIONISTS AT THIS
PROVIDER'S OFFICE
27. During your most recent visit, were clerks and
receptionists at this provider's office as helpful
as you thought they should be?
Yes, definitely
Yes, somewhat
No
28. During your most recent visit, did clerks and
receptionists at this provider's office treat you with
courtesy and respect?
Yes, definitely
Yes, somewhat
No
ABOUT YOU
29. In general, how would you rate your overall health?
Excellent
Very good
Good
Fair
Poor
30. In general, how would you rate your overall mental
or emotional health?
Excellent
Very good
Good
Fair
Poor

31. What is the highest grade or level of school
that you have completed?
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
32. Are you of Hispanic or Latino origin or descent?
Yes, Hispanic or Latino
No, not Hispanic or Latino
33. What is your race? Mark one or more.
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Other
34. Did someone help you complete this survey?
Yes
No  If No, go to ADDITIONAL
QUESTIONS ABOUT YOUR VISIT.
35. How did that person help you? Mark one or more.
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:

ADDITIONAL QUESTIONS ABOUT YOUR VISIT
Now that we have asked you to tell us about what happened during your visit, we ask you to rate the
services you received.

17. During your most recent visit, did this provider
listen carefully to you?
Yes, definitely
Yes, somewhat
No

25. Using any number from 0 to 10, where 0 is the
worst provider possible and 10 is the best provider
possible, what number would you use to rate this
provider?
0 Worst provider possible
1
2
3
4
5
6
7
8
9
10 Best provider possible

18. During your most recent visit, did you talk with this
provider about any health questions or concerns?
Yes
No  If No, go to #20

26. Would you recommend this provider's office to
your family and friends?
Yes, definitely
Yes, somewhat
No

MOVING THROUGH YOUR VISIT
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1. If you experienced delays, degree to which you were informed about these delays...
2. Wait time at practice (from scheduled appointment time to leaving)............................

INSTRUCTIONS: Mark the response that best describes your experience. If a question does not apply to
you, please skip to the next question. Space is provided for you to comment on your experiences.
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ACCESS
1
1. Ease of getting through to the practice on the phone ...................................................
2. Convenience of our office hours ...................................................................................
3. Ease of scheduling your appointment ..........................................................................
4. Courtesy of staff in the registration area .......................................................................

2

3

4

5

Comments (describe good or bad experience):
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Draft

16. During your most recent visit, did this provider
explain things in a way that was easy to understand?
Yes, definitely
Yes, somewhat
No

Comments (describe good or bad experience):

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