CAHPS Health Plan Survey Version Child Medicaid Survey 5.0
Please do not answer for any other children.
1. Our records show that your child is now in {INSERT HEALTH PLAN NAME}. Is that right?
Yes (If you choose "Yes", you will be directed to question #3)
No
2. What is the name of your child's health plan?
Plase print
Your Child’s Health Care in the Last 6 Months
These questions ask about your child’s health care. Do not include care your child got when he or she stayed overnight in a hospital. Do not include the times your child went for dental care visits.
3. In the last 6 months, did your child have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor’s office?
Yes
No (If you choose "No", you will be directed to question #5)
4. In the last 6 months, when your child needed care right away, how often did your child get care as soon as he or she needed?
Never
Sometimes
Usually
Always
5. In the last 6 months, did you make any appointments for a check-up or routine care for your child at a doctor’s office or clinic?
Yes
No (If you choose "No", you will be directed to question #7)
6. In the last 6 months, how often did you get an appointment for a check-up or routine care for your child at a doctor’s office or clinic as soon as your child needed?
Never
Sometimes
Usually
Always
7. In the last 6 months, not counting the times your child went to an emergency room, how many times did he or she go to a doctor’s office or clinic to get health care?
None (If you choose "None", you will be directed to question #10)
1 time
2
3
4
5 to 9
10 or more times
8. Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your child’s health care in the last 6 months?
0 Worst health care possible
1
2
3
4
5
6
7
8
9
10 Best health care possible
9. In the last 6 months, how often was it easy to get the care, tests, or treatment your child needed?
Never
Sometimes
Usually
Always
Your Child’s Personal Doctor
10. A personal doctor is the one your child would see if he or she needs a check-up, has a health problem or gets sick or hurt. Does your child have a personal doctor?
Yes
No (If you choose "No", you will be directed to question #20)
11. In the last 6 months, how many times did your child visit his or her personal doctor for care?
None (If you choose "None", you will be directed to question #19)
1 time
2
3
4
5 to 9
10 or more times
12. In the last 6 months, how often did your child’s personal doctor explain things about your child’s health in a way that was easy to understand?
Never
Sometimes
Usually
Always
13. In the last 6 months, how often did your child’s personal doctor listen carefully to you?
Never
Sometimes
Usually
Always
14. In the last 6 months, how often did your child’s personal doctor show respect for what you had to say?
Never
Sometimes
Usually
Always
15. Is your child able to talk with doctors about his or her health care?
Yes
No (If you choose "No", you will be directed to question #17)
16. In the last 6 months, how often did your child’s personal doctor explain things in a way that was easy for your child to understand?
Never
Sometimes
Usually
Always
17. In the last 6 months, how often did your child’s personal doctor spend enough time with your child?
Never
Sometimes
Usually
Always
18. In the last 6 months, did your child’s personal doctor talk with you about how your child is feeling, growing, or behaving?
Yes
No
19. Using any number from 0 to 10, where 0 is the worst personal doctor possible and 10 is the best personal doctor possible, what number would you use to rate your child’s personal doctor?
0 Worst personal doctor possible
1
2
3
4
5
6
7
8
9
10 Best personal doctor possible
Getting Health Care From Specialists
When you answer the next questions, do not include dental visits or care your child got when he or she stayed overnight in a hospital.
20. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 6 months, did you make any appointments for your child to see a specialist?
Yes
No (If you choose "No", you will be directed to question #24)
21. In the last 6 months, how often did you get appointments for your child to see a specialist as soon as he or she needed?
Never
Sometimes
Usually
Always
22. How many specialists has your child seen in the last 6 months?
None (If you choose "None", you will be directed to question #24)
1 specialist
2
3
4
5 or more specialists
23. We want to know your rating of the specialist your child saw most often in the last 6 months. Using any number from 0 to 10, where 0 is the worst specialist possible and 10 is the best specialist possible, what number would you use to rate that specialist?
0 Worst specialist possible
1
2
3
4
5
6
7
8
9
10 Best specialist possible
Your Child’s Health Plan
The next questions ask about your experience with your child’s health plan.
24. In the last 6 months, did you get information or help from customer service at your child’s health plan?
Yes
No (If you choose "No", you will be directed to question #27)
25. In the last 6 months, how often did customer service at your child’s health plan give you the information or help you needed?
Never
Sometimes
Usually
Always
26. In the last 6 months, how often did customer service staff at your child’s health plan treat you with courtesy and respect?
Never
Sometimes
Usually
Always
27. In the last 6 months, did your child’s health plan give you any forms to fill out?
Yes
No (If you choose "No", you will be directed to question #29)
28. In the last 6 months, how often were the forms from your child’s health plan easy to fill out?
Never
Sometimes
Usually
Always
29. Using any number from 0 to 10, where 0 is the worst health plan possible and 10 is the best health plan possible, what number would you use to rate your child’s health plan?
0 Worst health plan possible
1
2
3
4
5
6
7
8
9
10 Best health plan possible
About Your Child and You
30. In general, how would you rate your child’s overall health?
Excellent
Very Good
Good
Fair
Poor
31. In general, how would you rate your child’s overall mental or emotional health?
Excellent
Very Good
Good
Fair
Poor
32. What is your child’s age?
Less than 1 year old
...... YEARS OLD (write in)
33. Is your child male or female?
Male
Female
34. Is your child of Hispanic or Latino origin or descent?
Yes, Hispanic or Latino
No, not Hispanic and Latino
35. What is your child’s race? Mark one or more.
White
Black or African American
Asian
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Other
36. What is your age?
Under 18
18 to 24
25 to 34
35 to 44
45 to 54
55 to 64
65 to 74
75 or older
37. Are you male or female?
Male
Female
38. What is the highest grade or level of schoolthat you have completed?
8th grade or less
Some high school, but did notgraduate
High school graduate or GED
Some college or 2-year degree
4-year college graduate
More than 4-year college degree
39. How are you related to the child?
Mother or father
Grandparent
Aunt or uncle
Older brother or sister
Other relative
Legal guardian
Someone else
40. Did someone help you complete this survey?
Yes (If you choose "Yes", you will be directed to question #41
No
41. How did that person help you? Mark one or more.
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into mylanguage
Helped in some other way
Thank you.
Submit
Should be Empty: