CAHPS® Cancer Care Drug Therapy 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.
1. Our records show that you received care from the hospital or clinic listed below. Label with name of facility goes here. Is that right?
Yes No –› If No, go to #48
The remaining questions in this survey will refer to the hospital or clinic named in Question 1 as “this cancer center.” Please think of that facility as you answer the survey.
2. Has a doctor, nurse or other health care professional ever told you that you have cancer?
Yes No –› If No, go to #48
3. Drug therapy for cancer involves taking medicine to treat cancer. Examples of drug therapy are chemotherapy, immunotherapy, and hormonal therapy. Drug therapy does not include radiation therapy or surgery.Have you ever received drug therapy from this cancer center?
Yes No –› If No, go to #48
4. Is this cancer center the place you usually go to if you need a check-up, want advice about a health problem, or get sick or hurt?
Yes No
5. How long have you been treated at this cancer center for cancer?
Less than 6 months At least 6 months but less than 1 year At least 1 year but less than 2 years 2 years or more
6. When were you first diagnosed with your cancer?
Less than 6 months ago 6 months to 11 months ago 1 year to 2 years ago More than 2 years ago
7. Drug therapy team refers to the doctors, nurses, therapists, technicians, and their support staff involved with your drug therapy through this cancer center. Since it was decided that you would have drug therapy, did your drug therapy team encourage you to contact them with questions between visits?
Yes, definitely Yes, somewhat No
8. Since it was decided that you would have drug therapy, did your drug therapy team tell you to call them immediately if you have certain symptoms or side effects?
Yes, definitely Yes, somewhat No
9. Since it was decided that you would have drug therapy, did your drug therapy team give you clear instructions about how to contact them after regular office hours?
Yes, definitely Yes, somewhat No
10. Since it was decided that you would have drug therapy, did your drug therapy team involve your family members or close friends in discussions about your cancer or cancer care as much as you wanted?
Yes, definitely Yes, somewhat No
11. When was the last time you received drug therapy for cancer from this cancer center?
In the last 6 months More than 6 months ago –› If More than 6 months ago, go to #48
12. In the last 6 months, how many times did you visit this cancer center to get care from your drug therapy team? Do not include telephone calls or emails.
None –› If None, go to #48 1 to 5 times 6 to 10 times 11 or more times
13. In the last 6 months, did you contact this cancer center to get an appointment for an illness, injury, or condition that needed care right away?
Yes No –› If No, go to #15
14. In the last 6 months, when you contacted this cancer center to get an appointment for care you needed right away, how often did you get an appointment as soon as you needed?
Never Sometimes Usually Always
15. In the last 6 months, did you make any appointments for a check-up or routine care at this cancer center?
Yes No –› If No, go to #17
16. In the last 6 months, when you made an appointment for a check-up or routine care at this cancer center, how often did you get an appointment as soon as you needed?
Never Sometimes Usually Always
17. In the last 6 months, did you contact this cancer center with a medical question during regular office hours?
Yes No –› If No, go to #19
18. In the last 6 months, when you contacted this cancer center during regular office hours, how often did you get an answer to your medical question that same day?
Never Sometimes Usually Always
19. Drug therapy team refers to the doctors, nurses, therapists, technicians, and their support staff involved with your drug therapy through this cancer center. In the last 6 months, how often did your drug therapy team explain things in a way that was easy to understand?
Never Sometimes Usually Always
20. In the last 6 months, how often did your drug therapy team listen carefully to you?
Never Sometimes Usually Always
21. In the last 6 months, how often did your drug therapy team seem to know the important information about your medical history?
Never Sometimes Usually Always
22. In the last 6 months, how often did your drug therapy team show respect for what you had to say?
Never Sometimes Usually Always
23. In the last 6 months, how often did your drug therapy team spend enough time with you?
Never Sometimes Usually Always
24. In the last 6 months, did your drug therapy team order a blood test, x-ray, or other test for you? Do not include drug therapy.
Yes No –› If No, go to #26
25. In the last 6 months, when you had blood tests, x-rays, or other tests as part of your cancer treatment, how often did someone from this cancer center follow up to give you those results?
Never Sometimes Usually Always
26. In the last 6 months, did you take any prescription medicine?
Yes No –› If No, go to #28
27. In the last 6 months, how often did you and your drug therapy team talk about all the prescription medicines you were taking?
Never Sometimes Usually Always
28. In the last 6 months, did you and your drug therapy team talk about pain related to your cancer or drug therapy?
Yes No
29. In the last 6 months, were you bothered by pain from your cancer or drug therapy?
Yes No –› If No, go to #31
30. In the last 6 months, did your drug therapy team advise you about or help you deal with this pain?
Yes, definitely Yes, somewhat No
31. In the last 6 months, did you and your drug therapy team talk about any changes in your energy levels related to your cancer or drug therapy?
Yes No
32. In the last 6 months, were you bothered by changes in your energy levels related to your cancer or drug therapy?
Yes No –› If No, go to #34
33. In the last 6 months, did your drug therapy team advise you about or help you deal with these changes in your energy levels?
Yes, definitely Yes, somewhat No
34. In the last 6 months, did you and your drug therapy team talk about any emotional problems, such as anxiety or depression, related to your cancer or drug therapy?
Yes No
35. In the last 6 months, were you bothered by any emotional problems, such as anxiety or depression, related to your cancer or drug therapy?
Yes No –› If No, go to #37
36. In the last 6 months, did your drug therapy team advise you about or help you deal with these emotional problems?
Yes, definitely Yes, somewhat No
37. Additional services to manage your cancercare at home include home health care, special medical equipment, or special supplies. In the last 6 months, did you and your drug therapy team talk about these additional services?
Yes No
38. In the last 6 months, did you and your drug therapy team talk about things you can do to maintain your health during cancer treatment such as what to eat and what exercises to do?
Yes, definitely Yes, somewhat No
39. Using any number from 0 to 10, where 0 is the worst drug therapy team possible and 10 is the best drug therapy team possible, what number would you use to rate your drug therapy team?
0 Worst drug therapy team possible 1 2 3 4 5 6 7 8 9 10 Best drug therapy team possible
40. An interpreter is someone who helps you talk with others who do not speak your language. Interpreters can include staff from this cancer center, telephone interpreters, friends, or family members. In the last 6 months, was there any time when you needed an interpreter at this cancer center?
Yes No –› If No, go to #42
41. In the last 6 months, when you needed an interpreter to speak with your drug therapy team, how often did you get one?
Never Sometimes Usually Always
42. Considering all your cancer care at this cancer center, using any number from 0 to 10, where 0 is the worst overall cancer care experience possible and 10 is the best overall cancer care experience possible, what number would you use to rate your overall cancer care experience?
0 Worst overall cancer care experience possible 1 2 3 4 5 6 7 8 9 10 Best overall cancer care experience possible
43. In the last 6 months, how often were clerks and receptionists at this cancer center as helpful as you thought they should be?
Never Sometimes Usually Always
44. In the last 6 months, how often did clerks and receptionists at this cancer center treat you with courtesy and respect?
Never Sometimes Usually Always
45. Besides drug therapy, did you receive other types of cancer treatments or services from this cancer center?
Yes No
46. How do you prefer to make decisions about your cancer treatment?
You prefer to mainly make the decisions You prefer for you and your doctor to make the decisions together You prefer for your doctor to mainly make the decisions
47. In the last 6 months, did you have an overnight hospital stay for your cancer?
Yes No
48. In general, how would you rate your overall health?
Excellent Very Good Good Fair Poor
49. In general, how would you rate your overall mental or emotional health?
Excellent Very Good Good Fair Poor
50. What is your age?
18 to 20 21 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 or older
51. Are you male or female?
Male Female
52. What is the highest grade or level of school that you have completed?
8th grade or less Some high school, but did not graduate High school graduate or GED Some college or 2-year degree 4-year college graduate More than 4-year college degree
53. Are you of Hispanic or Latino origin or descent?
Yes, Hispanic or Latino No, not Hispanic or Latino
54. What is your race? Mark one or more.
White Black or African American Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other
55. Did someone help you complete this survey?
Yes No –› Thank you. Please return the completed survey in the postage-paid envelope.
56. 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 my language Helped in some other way
Should be Empty:

CAHPS® Cancer Care Drug Therapy Survey