9. CMS-10275. Attachment D.4_StandardTelephoneScriptEnglish_(final rule)

TELEPHONE INTERVIEW SCRIPT
FOR THE HOME HEALTH CARE CAHPS SURVEY
NOTE: USE THIS VERSION STARTING WITH APRIL 2026 SAMPLE
MONTH
INTRO1

Hello, may I please speak to [SAMPLE MEMBER’S NAME]?
1 YES [GO TO INTRO2]
2 NO, NOT AVAILABLE RIGHT NOW [SET CALLBACK]
3 NO [REFUSAL] [GO TO TERMINATE SCREEN]
4 MENTALLY/PHYSICALLY INCAPABLE [GO TO PROXY SCRIPT]
M MISSING/DK
IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [ORGANIZATION]. I’d like to
speak to [SAMPLE MEMBER’S NAME] about a health care study.
IF PERSON ON PHONE VOLUNTEERS THEY ARE SAMPLE MEMBER’S
PARTNER, CHILD, PARENT, SIBLING, GRANDCHILD, OR POWER OF
ATTORNEY AND THEY ASK WHY WE ARE CALLING:
I would like to talk to [SAMPLE MEMBER’S NAME] about their experiences
with the home health care that they received from [AGENCY NAME].

INTRO2

Hello, [SAMPLE MEMBER’S NAME], this is [INTERVIEWER FIRST &
LAST NAME] calling from [ORGANIZATION]. [HOME HEALTH AGENCY]
wants to learn about your recent experiences with home health care and asked me
to contact you.
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 SAMPLE MEMBER
BACK TO COMPLETE A SURVEY THAT WAS BEGUN IN A PREVIOUS
CALL. NOTE THAT THE SAMPLE MEMBER MUST HAVE ANSWERED
AT LEAST ONE QUESTION IN THE SURVEY IN A PRECEDING CALL.
Hello, may I please speak to [SAMPLE MEMBER’S NAME]?
IF ASKED WHO IS CALLING:
This is [INTERVIEWER NAME] calling from [VENDOR]. I’d like to speak to
[SAMPLE MEMBER’S NAME] about a study about health care.
1

YES, SAMPLE MEMBER 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]
4 MENTALLY/PHYSICALLY INCAPABLE [GO TO PROXY SCRIPT]

INTRO4

Hello, I am calling to continue the survey that we started in a previous call,
regarding the care that you 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, you got care from the home health agency, [AGENCY
NAME]. Is that right?
1 YES [GO TO Q2_INTRO]
2 NO [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 you got from staff from another home health care agency.

Q2.

When you first started getting home health care from this agency, did someone
from the agency talk about ways to help make your home safer? For example,
they may have suggested adding grab bars in the shower or removing tripping
hazards. Would you say…
1 Yes,
2 No,
3 You don’t know, or
4 You did not need help with home safety?
M MISSING/DK

Q3.

Has someone from the agency ever reviewed the prescribed and over-thecounter medicines you were taking? For example, they might have asked you to
show them your medicines and talked with you about how and when to take each
one? Would you say…
1
2
3
4

Yes,
No,
You don’t know, or
You don’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 you
about any side effects of your medicines? Would you say…
1
2
3
4

Yes,
No,
You don’t know, or
You don’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 you informed about when they would arrive at your 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 you were getting at home? Would
you say…
1 Never,
2 Sometimes,
3 Usually, or
4 Always?
M MISSING/DK

Q7.

In the last 2 months of care, how often did home health staff from this agency
treat you with care – for example, when moving you around or changing a
bandage? Would you say…
1 Never,
2 Sometimes,
3 Usually, or
4 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
2
3
4

Never,
Sometimes,
Usually, or
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 you? Would you say…
1 Never,
2 Sometimes,
3 Usually, or
4 Always?
M MISSING/DK

Q10.

In the last 2 months of care, how often did home health staff from this agency
treat you 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 you feel that home health staff from
the agency cared about you 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 your
family or friends with information or instructions about your care as much as
you wanted? Would you say…
1
2
3
4
M

Yes,
No,
You don’t know, or
You did not want or need this?
MISSING/DK

5

Q13.

In the last 2 months of care, how often have the services you received from this
agency helped you take care of your health? Would you say…
1
2
3
4
M

Never,
Sometimes,
Usually, or
Always?
MISSING/DK

Q14_INTRO We want to know your rating of your 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 you use to rate
your 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.

Have you 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 you contacted this agency’s office, did you get the help or advice you
needed?
1
2

YES
NO

M MISSING/DK
Q17.

Would you recommend this agency to your family or friends if they needed home
health care? Would you say…
1
2
3
4

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

M MISSING/DK
Q18_INTRO There are only a few questions left.
Q18.

In general, how would you rate your overall health? Would you say that it is…
1 Excellent,
2 Very good,
3 Good,
4 Fair, or
5 Poor?
M MISSING/DK

Q19.

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?

M MISSING/DK

7

Q20.

Do you live alone?
1
2

YES
NO

M MISSING/DK
Q21.

What is the highest grade or level of school that you have completed? Would you
say…
1 8th grade or less,
2 Some high school, but did not graduate,
3 High school graduate or GED,
4 Some college or 2-year degree,
5 4-year college graduate, or
6 More than 4-year college degree?
M MISSING/DK

Q22.

What is your race or ethnicity? You may choose one or more of the following.
Are you…
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 do you 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 23A]
M MISSING/DK [GO TO Q_END]

8

Q23A

What other language do you 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