CAHPS Clinician & Group Survey version 3.0 (Adult)

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.

1. Is that right? (If you choose No, you will be directed to question 23)

YesNo

2. Is this the the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?

YesNo

3. How long have you been going to this provider?

4. In the last 6 months, how many times did you visit this provider to get care for yourself? (If you choose None, you will be directed to question 23)

5. In the last 6 months, did you contact this provider’s office to get an appointment for an illness, injury, or condition that needed care right away? (If you choose No, you will be directed to question 7)

YesNo

6. In the last 6 months, when you contacted 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?

NeverSometimesUsuallyAlways

7. In the last 6 months, did you make any appointments for a check-up or routine care with this provider? (If you choose No, you will be directed to question 9)

YesNo

8. In the last 6 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?

NeverSometimesUsuallyAlways

9. In the last 6 months, did you contact this provider’s office with a medical question during regular office hours? (If you choose No, you will be directed to question 11)

YesNo

10. In the last 6 months, when you contacted this provider’s office during regular office hours, how often did you get an answer to your medical question that same day?

NeverSometimesUsuallyAlways

11. In the last 6 months, how often did this provider explain things in a way that was easy to understand?

NeverSometimesUsuallyAlways

12. In the last 6 months, how often did this provider listen carefully to you?

NeverSometimesUsuallyAlways

13. In the last 6 months, how often did this provider seem to know the important information about your medical history?

NeverSometimesUsuallyAlways

14. In the last 6 months, how often did this provider show respect for what you had to say?

NeverSometimesUsuallyAlways

15. In the last 6 months, how often did this provider spend enough time with you?

NeverSometimesUsuallyAlways

16. In the last 6 months, did this provider order a blood test, x-ray, or other test for you? (If you choose No, you will be directed to question 18)

YesNo

17. In the last 6 months, when this provider ordered a blood test, x-ray, or other test for you, how often did someone from this provider’s office follow up to give you those results?

NeverSometimesUsuallyAlways

18. 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?

19. In the last 6 months, did you take any prescription medicine? (If you choose No, you will be directed to question 21)

YesNo

20. In the last 6 months, how often did you and someone from this provider’s office talk about all the prescription medicines you were taking?

NeverSometimesUsuallyAlways

21. In the last 6 months, how often were clerks and receptionists at this provider’s office as helpful as you thought they should be?

NeverSometimesUsuallyAlways

22. In the last 6 months, how often did clerks and receptionists at this provider’s office treat you with courtesy and respect?

NeverSometimesUsuallyAlways

23. In general, how would you rate your overall health?

24. In general, how would you rate your overall mental or emotional health?

25. What is your age?

26. Are you male or female?

MaleFemale

27. What is the highest grade or level of school that you have completed?

28. Are you of Hispanic or Latino origin or descent?

Yes, Hispanic or LatinoNo, not Hispanic or Latino

29. What is your race? Mark one or more.

30. Did someone help you complete this survey?

YesNo

31. How did that person help you? Mark one or more.

CAHPS Clinician & Group Survey version 3.0 (Adult)

Name of provider label goes here

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.

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.

Clerks and Receptionists at This Provider’s Office