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March 2017 1

HCAHPS Survey

SURVEY INSTRUCTIONS

 You should only fill out this survey if you were the patient during the hospital stay
named in the cover letter. Do not fill out this survey if you were not the patient.

 Answer all the questions by checking 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 1

You may notice a number on the survey. This number is used to let us know if
you returned your survey so we don’t have to send you reminders.
Please note: Questions 1-25 in this survey are part of a national initiative to measure the quality
of care in hospitals. OMB #0938-0981

Please answer the questions in this survey

about your stay at the hospital named on

the cover letter. Do not include any other

hospital stays in your answers.

YOUR CARE FROM NURSES

1. During this hospital stay, how often

did nurses treat you with courtesy

and respect?

1
 Never

2
 Sometimes

3
 Usually

4
 Always

2. During this hospital stay, how often

did nurses listen carefully to you?

1
 Never

2
 Sometimes

3
 Usually

4
 Always

3. During this hospital stay, how often

did nurses explain things in a way

you could understand?

1
 Never

2
 Sometimes

3
 Usually

4
 Always

4. During this hospital stay, after you

pressed the call button, how often did

you get help as soon as you wanted

it?

1
 Never

2
 Sometimes

3
 Usually

4
 Always

9
 I never pressed the call button

2 March 2017

YOUR CARE FROM DOCTORS

5. During this hospital stay, how often

did doctors treat you with courtesy

and respect?

1
 Never

2
 Sometimes

3
 Usually

4
 Always

6. During this hospital stay, how often

did doctors listen carefully to you?

1
 Never

2
 Sometimes

3
 Usually

4
 Always

7. During this hospital stay, how often

did doctors explain things in a way

you could understand?

1
 Never

2
 Sometimes

3
 Usually

4
 Always

THE HOSPITAL ENVIRONMENT

8. During this hospital stay, how often

were your room and bathroom kept

clean?

1
 Never

2
 Sometimes

3
 Usually

4
 Always

9. During this hospital stay, how often

was the area around your room quiet

at night?

1
 Never

2
 Sometimes

3
 Usually

4
 Always

YOUR EXPERIENCES IN THIS HOSPITAL

10. During this hospital stay, did you

need help from nurses or other

hospital staff in getting to the

bathroom or in using a bedpan?

1
 Yes

2
 No  If No, Go to Question 12

11. How often did you get help in getting

to the bathroom or in using a bedpan

as soon as you wanted?

1
 Never

2
 Sometimes

3
 Usually

4
 Always

12. During this hospital stay, did you

need medicine for pain?

1
 Yes

2
 No  If No, Go to Question 15

13. During this hospital stay, how often

was your pain well controlled?

1
 Never

2
 Sometimes

3
 Usually

4
 Always

14. During this hospital stay, how often

did the hospital staff do everything

they could to help you with your pain?

1
 Never

2
 Sometimes

3
 Usually

4
 Always

March 2017 3

15. During this hospital stay, were you

given any medicine that you had not

taken before?

1
 Yes

2
 No  If No, Go to Question 18

16. Before giving you any new medicine,

how often did hospital staff tell you

what the medicine was for?

1
 Never

2
 Sometimes

3
 Usually

4
 Always

17. Before giving you any new medicine,

how often did hospital staff describe

possible side effects in a way you

could understand?

1
 Never

2
 Sometimes

3
 Usually

4
 Always

WHEN YOU LEFT THE HOSPITAL

18. After you left the hospital, did you go

directly to your own home, to

someone else’s home, or to another

health facility?

1
 Own home

2
 Someone else’s home

3
 Another health

facility  If Another, Go to

Question 21

19. During this hospital stay, did doctors,

nurses or other hospital staff talk with

you about whether you would have

the help you needed when you left the

hospital?

1
 Yes

2
 No

20. During this hospital stay, did you get

information in writing about what

symptoms or health problems to look

out for after you left the hospital?

1
 Yes

2
 No

OVERALL RATING OF HOSPITAL

Please answer the following questions

about your stay at the hospital named on

the cover letter. Do not include any other

hospital stays in your answers.

21. Using any number from 0 to 10, where

0 is the worst hospital possible and

10 is the best hospital possible, what

number would you use to rate this

hospital during your stay?

0
 0 Worst hospital possible

1
 1

2
 2

3
 3

4
 4

5
 5

6
 6

7
 7

8
 8

9
 9

10
10 Best hospital possible

4 March 2017

22. Would you recommend this hospital

to your friends and family?
1
 Definitely no

2
 Probably no

3
 Probably yes

4
 Definitely yes

UNDERSTANDING YOUR CARE

WHEN YOU LEFT THE HOSPITAL

23. During this hospital stay, staff took

my preferences and those of my

family or caregiver into account in

deciding what my health care needs

would be when I left.

1
 Strongly disagree

2
 Disagree

3
 Agree

4
 Strongly agree

24. When I left the hospital, I had a good

understanding of the things I was

responsible for in managing my

health.

1
 Strongly disagree

2
 Disagree

3
 Agree

4
 Strongly agree

25. When I left the hospital, I clearly

understood the purpose for taking

each of my medications.

1
 Strongly disagree

2
 Disagree

3
 Agree

4
 Strongly agree

5
 I was not given any medication when

I left the hospital

ABOUT YOU

There are only a few remaining items left.

26. During this hospital stay, were you

admitted to this hospital through the

Emergency Room?

1
 Yes

2
 No

27. In general, how would you rate your

overall health?

1
 Excellent

2
 Very good

3
 Good

4
 Fair

5
 Poor

28. In general, how would you rate your

overall mental or emotional health?

1
 Excellent

2
 Very good

3
 Good

4
 Fair

5
 Poor

29. What is the highest grade or level of

school that you have completed?

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

6
 More than 4-year college degree

March 2017 5

30. Are you of Spanish, Hispanic or

Latino origin or descent?

1
 No, not Spanish/Hispanic/Latino

2
 Yes, Puerto Rican

3
 Yes, Mexican, Mexican American,

Chicano
4
 Yes, Cuban

5
 Yes, other Spanish/Hispanic/Latino

31. What is your race? Please choose

one or more.

1
 White

2
 Black or African American

3
 Asian

4
 Native Hawaiian or other Pacific

Islander
5
 American Indian or Alaska Native

32. What language do you mainly speak

at home?

1
 English

2
 Spanish

3
 Chinese

4
 Russian

5
 Vietnamese

6
 Portuguese

9
 Some other language (please print):

_____________________

THANK YOU

Please return the completed survey in the postage-paid envelope.

[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING

HOSPITAL]

Questions 1-22 and 26-32 are part of the HCAHPS Survey and are works of the U.S.
Government. These HCAHPS questions are in the public domain and therefore are NOT
subject to U.S. copyright laws. The three Care Transitions Measure® questions (Questions
23-25) are copyright of Eric A. Coleman, MD, MPH, all rights reserved.

6 March 2017

March 2017 7

HCAHPS Survey

SURVEY INSTRUCTIONS

 You should only fill out this survey if you were the patient during the hospital stay named in the
cover letter. Do not fill out this survey if you were not the patient.

 Answer all the questions 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:

0 Yes

0 No  If No, Go to Question 1

You may notice a number on the survey. This number is used to let us know if you

returned your survey so we don’t have to send you reminders.
Please note: Questions 1-25 in this survey are part of a national initiative to measure the quality of care
in hospitals. OMB #0938-0981

Please answer the questions in this survey

about your stay at the hospital named on

the cover letter. Do not include any other

hospital stays in your answers.

YOUR CARE FROM NURSES

1. During this hospital stay, how often

did nurses treat you with courtesy

and respect?

10 Never
20 Sometimes
30 Usually
40 Always

2. During this hospital stay, how often

did nurses listen carefully to you?

10 Never
20 Sometimes
30 Usually
40 Always

3. During this hospital stay, how often

did nurses explain things in a way

you could understand?

10 Never
20 Sometimes
30 Usually
40 Always

4. During this hospital stay, after you

pressed the call button, how often did

you get help as soon as you wanted

it?

10 Never
20 Sometimes
30 Usually
40 Always
90 I never pressed the call button

8 March 2017

YOUR CARE FROM DOCTORS

5. During this hospital stay, how often

did doctors treat you with courtesy

and respect?

10 Never
20 Sometimes
30 Usually
40 Always

6. During this hospital stay, how often

did doctors listen carefully to you?

10 Never
20 Sometimes
30 Usually
40 Always

7. During this hospital stay, how often

did doctors explain things in a way

you could understand?

10 Never
20 Sometimes
30 Usually
40 Always

THE HOSPITAL ENVIRONMENT

8. During this hospital stay, how often

were your room and bathroom kept

clean?

10 Never
20 Sometimes
30 Usually
40 Always

9. During this hospital stay, how often

was the area around your room quiet

at night?

10 Never
20 Sometimes
30 Usually
40 Always

YOUR EXPERIENCES IN THIS HOSPITAL

10. During this hospital stay, did you

need help from nurses or other

hospital staff in getting to the

bathroom or in using a bedpan?

10 Yes
20 No  If No, Go to Question 12

11. How often did you get help in getting

to the bathroom or in using a bedpan

as soon as you wanted?

10 Never
20 Sometimes
30 Usually
40 Always

12. During this hospital stay, did you

need medicine for pain?

10 Yes
20 No  If No, Go to Question 15

13. During this hospital stay, how often

was your pain well controlled?

10 Never
20 Sometimes
30 Usually
40 Always

March 2017 9

14. During this hospital stay, how often

did the hospital staff do everything

they could to help you with your pain?

10 Never
20 Sometimes
30 Usually
40 Always

15. During this hospital stay, were you

given any medicine that you had not

taken before?

10 Yes
20 No  If No, Go to Question 18

16. Before giving you any new medicine,

how often did hospital staff tell you

what the medicine was for?

10 Never
20 Sometimes
30 Usually
40 Always

17. Before giving you any new medicine,

how often did hospital staff describe

possible side effects in a way you

could understand?

10 Never
20 Sometimes
30 Usually
40 Always

WHEN YOU LEFT THE HOSPITAL

18. After you left the hospital, did you go

directly to your own home, to

someone else’s home, or to another

health facility?

10 Own home
20 Someone else’s home
30 Another health

facility  If Another, Go to

Question 21

19. During this hospital stay, did doctors,

nurses or other hospital staff talk with

you about whether you would have

the help you needed when you left the

hospital?

10 Yes
20 No

20. During this hospital stay, did you get

information in writing about what

symptoms or health problems to look

out for after you left the hospital?

10 Yes
20 No

OVERALL RATING OF HOSPITAL

Please answer the following questions

about your stay at the hospital named on

the cover letter. Do not include any other

hospital stays in your answers.

21. Using any number from 0 to 10, where

0 is the worst hospital possible and

10 is the best hospital possible, what

number would you use to rate this

hospital during your stay?

00 0 Worst hospital possible
10 1
20 2
30 3
40 4
50 5
60 6
70 7
80 8
90 9

100 10 Best hospital possible

10 March 2017

22. Would you recommend this hospital

to your friends and family?

10 Definitely no
20 Probably no
30 Probably yes
40 Definitely yes

UNDERSTANDING YOUR CARE

WHEN YOU LEFT THE HOSPITAL

23. During this hospital stay, staff took

my preferences and those of my

family or caregiver into account in

deciding what my health care needs

would be when I left.

10 Strongly disagree
20 Disagree
30 Agree
40 Strongly agree

24. When I left the hospital, I had a good

understanding of the things I was

responsible for in managing my

health.

10 Strongly disagree
20 Disagree
30 Agree
40 Strongly agree

25. When I left the hospital, I clearly

understood the purpose for taking

each of my medications.

10 Strongly disagree
20 Disagree
30 Agree
40 Strongly agree
50 I was not given any medication when
I left the hospital

ABOUT YOU

There are only a few remaining items left.

26. During this hospital stay, were you

admitted to this hospital through the

Emergency Room?

10 Yes
20 No

27. In general, how would you rate your

overall health?

10 Excellent
20 Very good
30 Good
40 Fair
50 Poor

28. In general, how would you rate your

overall mental or emotional health?

10 Excellent
20 Very good
30 Good
40 Fair
50 Poor

29. What is the highest grade or level of

school that you have completed?

10 8th grade or less
20 Some high school, but did not

graduate
30 High school graduate or GED
40 Some college or 2-year degree
50 4-year college graduate
60 More than 4-year college degree

March 2017 11

30. Are you of Spanish, Hispanic or

Latino origin or descent?

10 No, not Spanish/Hispanic/Latino
20 Yes, Puerto Rican
30 Yes, Mexican, Mexican American,

Chicano
40 Yes, Cuban
50 Yes, other Spanish/Hispanic/Latino

31. What is your race? Please choose

one or more.

10 White
20 Black or African American
30 Asian
40 Native Hawaiian or other Pacific

Islander
50 American Indian or Alaska Native

32. What language do you mainly speak

at home?

10 English
20 Spanish
30 Chinese
40 Russian
50 Vietnamese
60 Portuguese
90 Some other language (please print):

_____________________

THANK YOU

Please return the completed survey in the postage-paid envelope.

[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]

[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING

HOSPITAL]

Questions 1-22 and 26-32 are part of the HCAHPS Survey and are works of the U.S.
Government. These HCAHPS questions are in the public domain and therefore are NOT
subject to U.S. copyright laws. The three Care Transitions Measure® questions (Questions
23-25) are copyright of Eric A. Coleman, MD, MPH, all rights reserved.

12 March 2017

March 2017 13

Sample Initial Cover Letter for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME]

[ADDRESS]

[CITY, STATE ZIP]

Dear [SAMPLED PATIENT NAME]:

Our records show that you were recently a patient at [NAME OF HOSPITAL] and discharged on

[DATE OF DISCHARGE (mm/dd/yyyy)]. Because you had a recent hospital stay, we are asking

for your help. This survey is part of an ongoing national effort to understand how patients view

their hospital experience. Hospital results will be publicly reported and made available on the

Internet at www.medicare.gov/hospitalcompare. These results will help consumers make

important choices about their hospital care, and will help hospitals improve the care they provide.

Questions 1-25 in the enclosed survey are part of a national initiative sponsored by the United

States Department of Health and Human Services to measure the quality of care in hospitals.

Your participation is voluntary and will not affect your health benefits.

We hope that you will take the time to complete the survey. Your participation is greatly

appreciated. After you have completed the survey, please return it in the pre-paid envelope. Your

answers may be shared with the hospital for purposes of quality improvement. [OPTIONAL: You

may notice a number on the survey. This number is used to let us know if you returned your

survey so we don’t have to send you reminders.]

If you have any questions about the enclosed survey, please call the toll-free number 1-800-xxx-

xxxx. Thank you for helping to improve health care for all consumers.

Sincerely,

[HOSPITAL ADMINISTRATOR]

[HOSPITAL NAME]

Note: The OMB Paperwork Reduction Act language must be included in the mailing. This

language can be either on the front or back of the cover letter or questionnaire, but cannot be a

separate mailing. The exact OMB Paperwork Reduction Act language is included in this

appendix. Please refer to the Mail Only, and Mixed Mode sections, for specific letter guidelines.

14 March 2017

March 2017 15

Sample Follow-up Cover Letter for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME]

[ADDRESS]

[CITY, STATE ZIP]

Dear [SAMPLED PATIENT NAME]:

Our records show that you were recently a patient at [NAME OF HOSPITAL] and discharged on

[DATE OF DISCHARGE (mm/dd/yyyy)]. Approximately three weeks ago we sent you a survey

regarding your hospitalization. If you have already returned the survey to us, please accept our

thanks and disregard this letter. However, if you have not yet completed the survey, please take a

few minutes and complete it now.

Because you had a recent hospital stay, we are asking for your help. This survey is part of an

ongoing national effort to understand how patients view their hospital experience. Hospital

results will be publicly reported and made available on the Internet at

www.medicare.gov/hospitalcompare. These results will help consumers make important choices

about their hospital care, and will help hospitals improve the care they provide.

Questions 1-25 in the enclosed survey are part of a national initiative sponsored by the United

States Department of Health and Human Services to measure the quality of care in hospitals.

Your participation is voluntary and will not affect your health benefits. Please take a few minutes

and complete the enclosed survey. After you have completed the survey, please return it in the

pre-paid envelope. Your answers may be shared with the hospital for purposes of quality

improvement. [OPTIONAL: You may notice a number on the survey. This number is used to let

us know if you returned your survey so we don’t have to send you reminders.]

If you have any questions about the enclosed survey, please call the toll-free number 1-800-xxx-

xxxx. Thank you again for helping to improve health care for all consumers.

Sincerely,

[HOSPITAL ADMINISTRATOR]

[HOSPITAL NAME]

Note: The OMB Paperwork Reduction Act language must be included in the mailing. This

language can be either on the front or back of the cover letter or questionnaire, but cannot be a

separate mailing. The exact OMB Paperwork Reduction Act language is included in this

appendix. Please refer to the Mail Only, and Mixed Mode sections, for specific letter guidelines.

16 March 2017

March 2017 17

OMB Paperwork Reduction Act Language

The OMB Paperwork Reduction Act language must be included in the survey mailing. This

language can be either on the front or back of the cover letter or questionnaire, but cannot be a

separate mailing. The following is the language that must be used:

English Version

“According to the Paperwork Reduction Act of 1995, no persons are required to respond to a

collection of information unless it displays a valid OMB control number. The valid OMB control

number for this information collection is 0938-0981. The time required to complete this

information collected is estimated to average 8 minutes for questions 1-25 on the survey,

including the time to review instructions, search existing data resources, gather the data needed,

and complete and review the information collection. If you have any comments concerning the

accuracy of the time estimate(s) or suggestions for improving this form, please write to: Centers

for Medicare & Medicaid Services, 7500 Security Boulevard, C1-25-05, Baltimore, MD 21244-

1850.”

18 March 2017


 

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