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?

YesNo –› 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?

YesNo –› 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?

YesNo –› 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?

YesNo

5. How long have you been treated at this cancer center for cancer?

Less than 6 monthsAt least 6 months but less than 1 yearAt least 1 year but less than 2 years2 years or more

6. When were you first diagnosed with your cancer?

Less than 6 months ago6 months to 11 months ago1 year to 2 years agoMore 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, definitelyYes, somewhatNo

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, definitelyYes, somewhatNo

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, definitelyYes, somewhatNo

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, definitelyYes, somewhatNo

11. When was the last time you received drug therapy for cancer from this cancer center?

In the last 6 monthsMore 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 #481 to 5 times6 to 10 times11 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?

YesNo –› 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?

NeverSometimesUsuallyAlways

15. In the last 6 months, did you make any appointments for a check-up or routine care at this cancer center?

YesNo –› 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?

NeverSometimesUsuallyAlways

17. In the last 6 months, did you contact this cancer center with a medical question during regular office hours?

YesNo –› 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?

NeverSometimesUsuallyAlways

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?

NeverSometimesUsuallyAlways

20. In the last 6 months, how often did your drug therapy team listen carefully to you?

NeverSometimesUsuallyAlways

21. In the last 6 months, how often did your drug therapy team seem to know the important information about your medical history?

NeverSometimesUsuallyAlways

22. In the last 6 months, how often did your drug therapy team show respect for what you had to say?

NeverSometimesUsuallyAlways

23. In the last 6 months, how often did your drug therapy team spend enough time with you?

NeverSometimesUsuallyAlways

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.

YesNo –› 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?

NeverSometimesUsuallyAlways

26. In the last 6 months, did you take any prescription medicine?

YesNo –› 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?

NeverSometimesUsuallyAlways

28. In the last 6 months, did you and your drug therapy team talk about pain related to your cancer or drug therapy?

YesNo

29. In the last 6 months, were you bothered by pain from your cancer or drug therapy?

YesNo –› 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, definitelyYes, somewhatNo

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?

YesNo

32. In the last 6 months, were you bothered by changes in your energy levels related to your cancer or drug therapy?

YesNo –› 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, definitelyYes, somewhatNo

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?

YesNo

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?

YesNo –› 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, definitelyYes, somewhatNo

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?

YesNo

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, definitelyYes, somewhatNo

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?

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?

YesNo –› 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?

NeverSometimesUsuallyAlways

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?

43. In the last 6 months, how often were clerks and receptionists at this cancer center as helpful as you thought they should be?

NeverSometimesUsuallyAlways

44. In the last 6 months, how often did clerks and receptionists at this cancer center treat you with courtesy and respect?

NeverSometimesUsuallyAlways

45. Besides drug therapy, did you receive other types of cancer treatments or services from this cancer center?

YesNo

46. How do you prefer to make decisions about your cancer treatment?

You prefer to mainly make the decisionsYou prefer for you and your doctor to make the decisions togetherYou 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?

YesNo

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

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

50. What is your age?

51. Are you male or female?

MaleFemale

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

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

Yes, Hispanic or LatinoNo, not Hispanic or Latino

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

55. Did someone help you complete this survey?

YesNo –› Thank you. Please return the completed survey in the postage-paid envelope.

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