CAHPS Child Hospital Survey

CAHPS Child Hospital Survey
Survey Instructions
Answer each question by marking 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 be directed to what question to answer next.
Do not include any other hospital stays in your answers.
When Your Child Was Admitted to this Hospital
1. Was your child born during this hospital stay?
Yes (If you choose Yes, you will be directed to question 14)No
2. For this hospital stay, was your child admitted through this hospital’s Emergency Room?
YesNo (If you choose No, you will be directed to question 5)
3. Were you in this hospital’s Emergency Room with your child?
YesNo (If you choose No, you will be directed to question 5)
4. While your child was in this hospital’s Emergency Room, were you kept informed about what was being done for your child?
Yes, definitelyYes, somewhatNo
5. During the first day of this hospital stay, were you asked to list or review all of the prescription medicines your child was taking at home?
Yes, definitelyYes, somewhatNo
6. During the first day of this hospital stay, were you asked to list or review all of the vitamins, herbal medicines, and over-the-counter medicines your child was taking at home?
Yes, definitelyYes, somewhatNo
Your Child’s Care After Admission to this Hospital
Do not include care received in the Emergency Room for the rest of the survey.
7. Is your child able to talk with nurses and doctors about his or her health care?
YesNo (If you choose No, you will be directed to question 14)
Your Child’s Experience with Nurses
The next questions ask about your child’s experience during this hospital stay. You will be asked about your own experience during this hospital stay in later questions.
8. During this hospital stay, how often did your child’s nurses listen carefully to your child?
NeverSometimesUsuallyAlways
9. During this hospital stay, how often did your child’s nurses explain things in a way that was easy for your child to understand?
NeverSometimesUsuallyAlways
10. During this hospital stay, how often did your child’s nurses encourage your child to ask questions?
NeverSometimesUsuallyAlways
Your Child’s Experience with Doctors
11. During this hospital stay, how often did your child’s doctors listen carefully to your child?
NeverSometimesUsuallyAlways
12. During this hospital stay, how often did your child’s doctors explain things in a way that was easy for your child to understand?
NeverSometimesUsuallyAlways
13. During this hospital stay, how often did your child’s doctors encourage your child to ask questions?
NeverSometimesUsuallyAlways
Your Experience with Nurses
14. During this hospital stay, how often did your child’s nurses listen carefully to you?
NeverSometimesUsuallyAlways
15. During this hospital stay, how often did your child’s nurses explain things to you in a way that was easy to understand?
NeverSometimesUsuallyAlways
16. During this hospital stay, how often did your child’s nurses treat you with courtesy and respect?
NeverSometimesUsuallyAlways
Your Experience with Doctors
17. During this hospital stay, how often did your child’s doctors listen carefully to you?
NeverSometimesUsuallyAlways
18. During this hospital stay, how often did your child’s doctors explain things to you in a way that was easy to understand?
NeverSometimesUsuallyAlways
19. During this hospital stay, how often did your child’s doctors treat you with courtesy and respect?
NeverSometimesUsuallyAlways
Your Experience with Providers
20. A provider in the hospital can be a doctor, nurse, nurse practitioner, or physician assistant. During this hospital stay, how often were you given as much privacy as you wanted when discussing your child’s care with providers?
NeverSometimesUsuallyAlways
21. Things that a family might know best about a child include how the child usually acts, what makes the child comfortable, and how to calm the child’s fears. During this hospital stay, did providers ask you about these types of things?
Yes, definitelyYes, somewhatNo
22. During this hospital stay, how often did providers talk with and act toward your child in a way that was right for your child’s age?
NeverSometimesUsuallyAlways
23. During this hospital stay, how often did providers keep you informed about what was being done for your child?
NeverSometimesUsuallyAlways
24. Tests in the hospital can include things like blood tests and x-rays. During this hospital stay, did your child have any tests?
YesNo (If you choose No, you will be directed to question 26)
25. How often did providers give you as much information as you wanted about the results of these tests?
NeverSometimesUsuallyAlways
Your Child’s Care in this Hospital
26. During this hospital stay, did you or your child ever press the call button?
YesNo (If you choose No, you will be directed to question 28)
27. After pressing the call button, how often was help given as soon as you or your child wanted it?
NeverSometimesUsuallyAlways
28. During this hospital stay, was your child given any medicine?
YesNo (If you choose No, you will be directed to question 30)
29. Before giving your child any medicine, how often did providers or other hospital staff check your child’s wristband or confirm his or her identity in some other way?
NeverSometimesUsuallyAlways
30. Mistakes in your child’s health care can include things like giving the wrong medicine or doing the wrong surgery. During this hospital stay, did providers or other hospital staff tell you how to report if you had any concerns about mistakes in your child’s health care?
Yes, definitelyYes, somewhatNo
31. During this hospital stay, did your child have pain that needed medicine or other treatment?
YesNo (If you choose No, you will be directed to question 33)
32. During this hospital stay, did providers or other hospital staff ask about your child’s pain as often as your child needed?
Yes, definitelyYes, somewhatNo
The Hospital Environment
33. During this hospital stay, how often were your child’s room and bathroom kept clean?
NeverSometimesUsuallyAlways
34. During this hospital stay, how often was the area around your child’s room quiet at night?
NeverSometimesUsuallyAlways
35. Hospitals can have things like toys, books, mobiles, and games for children from newborns to teenagers. During this hospital stay, did the hospital have things available for your child that were right for your child’s age?
Yes, definitelyYes, somewhatNo
When Your Child Left this Hospital
36. As a reminder, a provider in the hospital can be a doctor, nurse, nurse practitioner, or physician assistant. Before your child left the hospital, did a provider ask you if you had any concerns about whether your child was ready to leave?
Yes, definitelyYes, somewhatNo
37. Before your child left the hospital, did a provider talk with you as much as you wanted about how to care for your child’s health after leaving the hospital?
Yes, definitelyYes, somewhatNo
38. Before your child left the hospital, did a provider tell you that your child should take any new medicine that he or she had not been taking when this hospital stay began?
YesNo (If you choose No, you will be directed to question 41)
39. Before your child left the hospital, did a provider or hospital pharmacist explain in a way that was easy to understand how your child should take these new medicines after leaving the hospital?
Yes, definitelyYes, somewhatNo
40. Before your child left the hospital, did a provider or hospital pharmacist explain in a way that was easy to understand about possible side effects of these new medicines?
Yes, definitelyYes, somewhatNo
41. A child’s regular activities can include things like eating, bathing, going to school, or playing sports. Before your child left the hospital, did a provider explain in a way that was easy to understand when your child could return to his or her regular activities?
Yes, definitelyYes, somewhatNo
42. Before your child left the hospital, did a provider explain in a way that was easy to understand what symptoms or health problems to look out for after your child left the hospital?
Yes, definitelyYes, somewhatNo
43. Before your child left the hospital, did you get information in writing about what symptoms or health problems to look out for after your child left the hospital?
Yes, definitelyYes, somewhatNo
When Your Child Left this Hospital
44. During this hospital stay, was your child 13 years old or older?
YesNo (If you choose No, you will be directed to question 48)
45. During this hospital stay, how often did providers involve your child in discussions about his or her health care?
NeverSometimesUsuallyAlways
46. Before your child left the hospital, did a provider ask your child if he or she had any concerns about whether he or she was ready to leave?
Yes, definitelyYes, somewhatNo
47. Before your child left the hospital, did a provider talk with your child about how to take care of his or her health after leaving the hospital?
Yes, definitelyYes, somewhatNo
Overall Rating of This Hospital
As a reminder, please answer the questions about the child and hospital named in the cover letter. Do not include any other hospital stays in your answers.
48. 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 child’s stay?

0
1
2
3
4
5
6
7
8
9
10
0 is Worst hospital possible, 10 is Best hospital possible
49. Would you recommend this hospital to your friends and family?
Definitely noProbably noProbably yesDefinitely yes
About Your Child
50. In general, how would you rate your child’s overall health?
ExcellentVery goodGoodFairPoor
51. What is your child’s age?
Les than 1 year oldOther
52. Is your child male or female?
MaleFemale
53. Is your child of Hispanic or Latino origin or descent?
Yes, Hispanic or LatinoNo, not Hispanic or Latino
54. What is your child’s race? Mark one or more.
WhiteBlack or African AmericanNative Hawaiian or other PacificIslanderAmerican Indian or Alaska NativeOther
About You
55. How are you related to the child?
MotherFatherGrandmotherGrandfatherOther relative or legal guardianSomeone else
56. What is your age?
Under 1818-2425-3435-4445-5455-6465-7475 and older
57. What is the highest grade or level of school that you have completed?
8th grade or lessSome high school, but did not graduateHigh school graduate or GEDSome college or 2-year degree4-year college graduateMore than 4-year college degree
58. What is your preferred language?
EnglishSpanishChineseVietnameseKoreanRussianOther language
59. During your child’s hospital stay, how much of the time were you at the hospital?
None of the timeA little of the timeSome of the timeMost of the timeAll or nearly all of the time
60. Is there anything else you would like to sayabout the care your child received duringthis hospital stay?
Please print
61. Did someone help you complete this survey?
YesNo
62. How did that person help you? Mark one or more.
Read the questions to meWrote down the answers I gaveAnswered the questions for meTranslated the questions into mylanguage Helped in some other way
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CAHPS Child Hospital Survey

When Your Child Was Admitted to this Hospital

Your Child’s Care After Admission to this Hospital

Your Child’s Experience with Nurses

Your Child’s Experience with Doctors

Your Experience with Nurses

Your Experience with Doctors

Your Experience with Providers

Your Child’s Care in this Hospital

The Hospital Environment

When Your Child Left this Hospital

When Your Child Left this Hospital

Overall Rating of This Hospital

About Your Child

About You