8. CMS-10275. Attachment D.3_ProxyTelephoneScriptEnglish_(final rule)

PROXY TELEPHONE INTERVIEW SCRIPT
FOR THE HOME HEALTH CARE CAHPS SURVEY
NOTE: USE THIS VERSION STARTING WITH APRIL 2026 SAMPLE
MONTH
PROXY ID

Is there somebody such as a family member or friend who is familiar with
[SAMPLE MEMBER’S NAME]’s health care experiences?
PROBE TO FIND OUT IF PERSON IS AVAILABLE IN HOUSEHOLD TO DO
INTERVIEW.
1
2

YES
[GO TO PROXY_INTRO]
NO
[COLLECT NAME AND TELEPHONE NUMBER OF PROXY
AND SET A CALLBACK, OR IF NO PROXY EXISTS, GO TO Q_END
AND CODE AS MENTALLY/PHYSICALLY INCAPABLE]

IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [ORGANIZATION]. I’d like to
speak with someone who is knowledgeable about [SAMPLE MEMBER
NAME]’s health and health care experiences for a study [ORGANIZATION] is
conducting about health care.
PROXY_INTRO
[Hello, this is {INTERVIEWER FIRST & LAST NAME} calling from
{HOME HEALTH AGENCY}]. [HOME HEALTH AGENCY] wants to learn
about [SAMPLE MEMBER NAME]’s recent experiences with home health care.
Your feedback will help improve the quality of care [HOME HEALTH
AGENCY] provides and help Medicare improve the overall quality of home
health care.
Your participation is voluntary and completely confidential. We would really
appreciate your feedback and my questions will take about 9 minutes.
This call may be monitored or recorded for quality improvement purposes.
NOTE: THE LENGTH OF THE INTERVIEW WILL DEPEND ON
WHETHER THE HHA ADDS SUPPLEMENTAL QUESTIONS TO ITS
HOME HEALTH CARE CAHPS SURVEY.

1

INTRO3

INTRO3 AND INTRO4 USED ONLY IF CALLING PROXY BACK TO
COMPLETE A SURVEY THAT WAS BEGUN IN A PREVIOUS CALL.
NOTE THAT THE PROXY MUST HAVE ANSWERED AT LEAST ONE
QUESTION IN THE SURVEY IN A PRECEDING CALL.
Hello, may I please speak to [PROXY NAME]?
IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [VENDOR]. I’d like to speak to
[PROXY NAME] about a study about health care.
1

YES, PROXY IS AVAILABLE AND ON PHONE NOW [GO TO
INTRO4]
2 NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]
3 NO [REFUSAL] [GO TO Q_REF SCREEN]

INTRO4

Hello, I am calling to continue the survey that we started in a previous call,
regarding the care that [SAMPLE MEMBER NAME] received from [AGENCY
NAME]. I’d like to continue with the interview now.
1
2
3

Q1.

CONTINUE WITH INTERVIEW AT FIRST UNANSWERED QUESTION
NO, NOT RIGHT NOW [SET CALLBACK]
NO [REFUSAL] [GO TO Q_REF SCREEN]

According to our records, [SAMPLE MEMBER NAME] got care from the home
health agency, [AGENCY NAME]. Is that right?
1
2

YES
NO

[GO TO Q2_INTRO]
[GO TO Q_INELIG]

M MISSING/DK

[GO TO Q_INELIG]

2

Q2_INTRO

These next questions are about all the different staff from [AGENCY NAME].
Do not include care [SAMPLE MEMBER NAME] got from staff from another
home health care agency.

Q2.

When [SAMPLE MEMBER NAME] first started getting home health care from
this agency, did someone from the agency talk about ways to help make
[his/her] home safer? For example, they may have suggested adding grab bars in
the shower or removing tripping hazards. Would you say…
1
2
3
4

Yes,
No,
You don’t know, or
[SAMPLE MEMBER NAME] did not need help with home safety?

M MISSING/DK
Q3.

Has someone from the agency ever reviewed the prescribed and over-thecounter medicines [SAMPLE MEMBER NAME] was taking? For example, they
might have asked [him/her] to show them [his/her] medicines and talked with
[SAMPLE MEMBER NAME] about how and when to take each one? Would you
say…
1 Yes,
2 No,
3 You don’t know, or
4 [SAMPLE MEMBER NAME] doesn’t take any medicines? GO TO Q5
M MISSING/DK

Q4.

In the last 2 months of care, did home health staff from this agency talk with
[SAMPLE MEMBER NAME] about any side effects of [his/her] medicines?
Would you say…
1 Yes,
2 No,
3 You don’t know, or
4 [SAMPLE MEMBER NAME] doesn’t take any medicines?
M MISSING/DK

3

Q5.

In the last 2 months of care, how often did home health staff from this agency
keep [SAMPLE MEMBER NAME] informed about when they would arrive at
[his/her] home? Would you say…
1
2
3
4

Never,
Sometines,
Usually, or
Always?

M MISSING/DK
Q6.

In the last 2 months of care, how often did home health staff from this agency
seem to be aware of all the care or treatment [SAMPLE MEMBER NAME]
was getting at home? Would you say…
1
2
3
4

Never,
Sometimes,
Usually, or
Always?

M MISSING/DK
Q7.

In the last 2 months of care, how often did home health staff from this agency
treat [SAMPLE MEMBER NAME] with care – for example, when moving
[him/her] around or changing a bandage? Would you say…
1
2
3
4

Never,
Sometimes,
Usually, or
Always?

M MISSING/DK
Q8.

In the last 2 months of care, how often did home health staff from this agency
explain things in a way that was easy to understand? Would you say…
1 Never,
2 Sometimes,
3 Usually, or
4 Always?
M MISSING/DK

4

Q9.

In the last 2 months of care, how often did home health staff from this agency
listen carefully to [SAMPLE MEMBER NAME]? Would you say…
1
2
3
4

Never,
Sometimes,
Usually, or
Always?

M MISSING/DK
Q10.

In the last 2 months of care, how often did home health staff from this agency
treat [SAMPLE MEMBER NAME] with courtesy and respect? Would you
say…
1 Never,
2 Sometimes,
3 Usually, or
4 Always?
M MISSING/DK

Q11.

In the last 2 months of care, how often did [SAMPLE MEMBER NAME] feel
that home health staff from the agency cared about [him/her] as a person?
Would you say…
1 Never,
2 Sometimes,
3 Usually, or
4 Always?
M MISSING/DK

Q12.

In the last 2 months of care, did home health staff from this agency provide
[SAMPLE MEMBER NAME]’s family or friends with information or
instructions about [his/her] care as much as [he/she] wanted? Would you say…
1 Yes,
2 No,
3 You don’t know, or
4 [SAMPLE MEMBER NAME] did not want or need this?
M MISSING/DK

5

Q13.

In the last 2 months of care, how often have the services [SAMPLE MEMBER
NAME] received from this agency helped [SAMPLE MEMBER NAME] take
care of [his/her] health? Would you say…
1
2
3
4

Never,
Sometimes,
Usually, or
Always?

M MISSING/DK
Q14_INTRO We want to know [SAMPLE MEMBER NAME]’s rating of [his/her] care from
this agency’s home health staff.
Q14.

Using any number from 0 to 10, where 0 is the worst home health care possible
and 10 is the best home health care possible, what number would [SAMPLE
MEMBER NAME] use to rate [his/her] care from this agency’s home health
staff?
READ RESPONSE CHOICES ONLY IF NECESSARY
00
01
02
03
04
05
06
07
08
09
10

0 Worst home health care possible
1
2
3
4
5
6
7
8
9
10 Best home health care possible

M MISSING/DK
Q15_INTRO The next questions are about the office of [AGENCY NAME].
Q15.

Has [SAMPLE MEMBER NAME] contacted this agency’s office for help or
advice?
1
2

YES
NO [GO TO Q17]

M MISSING/DK

[GO TO Q17]
6

Q16.

When [SAMPLE MEMBER NAME] contacted this agency’s office, did
[SAMPLE MEMBER NAME] get the help or advice [he/she] needed?
1 YES
2 NO
M MISSING/DK

Q17.

Would [SAMPLE MEMBER NAME] recommend this agency to [his/her] family
or friends if they needed home health care? Would you say…
1 Definitely no,
2 Probably no,
3 Probably yes, or
4 Definitely yes?
M MISSING/DK

Q18_INTRO There are only a few questions left. If you are answering on behalf of a family
member or friend who received home health care: these questions are about
that person, not yourself.
Q18.

In general, how would [SAMPLE MEMBER NAME] rate [his/her] overall
health? Would you say that it is…
1
2
3
4
5

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

M MISSING/DK
Q19.

In general, how would [SAMPLE MEMBER NAME] rate [his/her] overall
mental or emotional health? Would you say that it is…
1 Excellent,
2 Very good,
3 Good,
4 Fair, or
5 Poor?
M MISSING/DK

7

Q20.

Does [SAMPLE MEMBER NAME] live alone?
1
2

YES
NO

M MISSING/DK
Q21.

What is the highest grade or level of school that [SAMPLE MEMBER NAME]
has completed? Would you say…
1
2
3
4
5
6

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, or
More than 4-year college degree?

M MISSING/DK
Q22.

What is [SAMPLE MEMBER NAME]’s race or ethnicity? You may choose one
or more of the following. Is he/she…
1
2
3
4
5
6
7

American Indian or Alaska Native,
Asian,
Black or African American,
Hispanic or Latino,
Middle Eastern or North African,
Native Hawaiian or Pacific Islander, or
White?

M MISSING/DK
Q23.

What language does [SAMPLE MEMBER NAME] mainly speak at home?
Would you say…
1 English, [GO TO Q_END]
2 Spanish, or [GO TO Q_END]
3 Some other language? [GO TO Q23A]
M MISSING/DK [GO TO Q_END]

8

Q23A

What other language does [SAMPLE MEMBER NAME] mainly speak at home?
(ENTER RESPONSE BELOW).
{ALLOW UP TO 50 CHARACTERS}
M MISSING/DK

Q_END

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

INELIGIBLE SCREEN:
Q_INELIG

Thank you for your time. Have a good (day/evening).

REFUSAL SCREEN:
Q_REF

Thank you for your time. Have a good (day/evening).

9