ࡱ> ] objbjzpzp Ӗ b b0T66DvZtPD((((((()))OOOOOOO$R8UTO)))"))O((((XP222)F((((O2)O22JO(( ׇ4*M,mOnP0PM(W+FWXOWOP))2)))))OO/)))P))))W)))))))))6B x:  CAHPS Dental Plan Survey Version: Adult Language: English For assistance with this survey, please contact the CAHPS Help Line at 800-492-9261 or  HYPERLINK "mailto:cahps1@westat.com" cahps1@westat.com. File name:  FILENAME \* MERGEFORMAT dental-plan-adult-eng-751.doc Last updated: February 10, 2009 Instructions for Front Cover Replace the cover of this document with your own front cover. Include a user-friendly title and your own logo. Include this text regarding the confidentiality of survey responses: Your Privacy is Protected. All information that would let someone identify you or your family will be kept private. {VENDOR NAME} will not share your personal information with anyone without your OK. Your responses to this survey are also completely confidential. You may notice a number on the cover of the survey. This number is used only to let us know if you returned your survey so we dont have to send you reminders. Your Participation is Voluntary. You may choose to answer this survey or not. If you choose not to, this will not affect the dental care you get. What To Do When Youre Done. Once you complete the survey, place it in the envelope that was provided, seal the envelope, and return the envelope to [INSERT VENDOR ADDRESS]. If you want to know more about this study, please call XXX-XXX-XXXX. Instructions for Format of Questionnaire Proper formatting of a questionnaire improves response rates, the ease of completion, and the accuracy of responses. The CAHPS teams recommendations include the following: If feasible, insert blank pages as needed so that the survey instructions (see next page) and the first page of questions start on the right-hand side of the questionnaire booklet. Maximize readability by using two columns, serif fonts for the questions, and ample white space. Number the pages of your document, but remove the headers and footers inserted to help sponsors and vendors distinguish among questionnaire versions. 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 see an arrow with a note that tells you what question to answer next, like this:  FORMCHECKBOX  Yes ( If Yes, go to #1 on page 1  FORMCHECKBOX  No 1. Our records show that you are now in the {insert dental plan name}. Is that right? 1 FORMCHECKBOX  Yes ( If Yes, go to #3 2 FORMCHECKBOX  No 2. What is the name of your dental plan? Please print: 3. In the last 12 months, did you go to a dentists office or clinic for care? 1 FORMCHECKBOX  Yes 2 FORMCHECKBOX  No ( If No, please stop and return this survey in the postage-paid envelope. Thank you. Your Regular Dentist 4. A regular dentist is one you would go to for check-ups and cleanings or when you have a cavity or tooth pain. Do you have a regular dentist? 1 FORMCHECKBOX  Yes 2 FORMCHECKBOX  No ( If No, go to #11 5. Have you seen your regular dentist in the last 12 months? 1 FORMCHECKBOX  Yes 2 FORMCHECKBOX  No, I ve seen someone else ( If No, goto#11 6. In the last 12 months, how often did your regular dentist explain things in a way that was easy to understand? 1 FORMCHECKBOX  Never 2 FORMCHECKBOX  Sometimes 3 FORMCHECKBOX  Usually 4 FORMCHECKBOX  Always 7. In the last 12 months, how often did your regular dentist listen carefully to you? 1 FORMCHECKBOX  Never 2 FORMCHECKBOX  Sometimes 3 FORMCHECKBOX  Usually 4 FORMCHECKBOX  Always 8. In the last 12 months, how often did your regular dentist treat you with courtesy and respect? 1 FORMCHECKBOX  Never 2 FORMCHECKBOX  Sometimes 3 FORMCHECKBOX  Usually 4 FORMCHECKBOX  Always 9. In the last 12 months, how often did your regular dentist spend enough time with you? 1 FORMCHECKBOX  Never 2 FORMCHECKBOX  Sometimes 3 FORMCHECKBOX  Usually 4 FORMCHECKBOX  Always 10. Using any number from 0 to 10, where 0 is the worst regular dentist possible and 10 is the best regular dentist possible, what number would you use to rate your regular dentist?  FORMCHECKBOX  0 Worst regular dentist possible  FORMCHECKBOX  1  FORMCHECKBOX  2  FORMCHECKBOX  3  FORMCHECKBOX  4  FORMCHECKBOX  5  FORMCHECKBOX  6  FORMCHECKBOX  7  FORMCHECKBOX  8  FORMCHECKBOX  9  FORMCHECKBOX  10 Best regular dentist possible Your Dental Care in the Last 12 Months So far, the questions on this survey have been about your regular dentist. The next set of questions asks about any dental care you had in the last 12 months, including dental care with your regular dentist or with someone else. 11. In the last 12 months, how often did the dentists or dental staff do everything they could to help you feel as comfortable as possible during your dental work? 1 FORMCHECKBOX  Never 2 FORMCHECKBOX  Sometimes 3 FORMCHECKBOX  Usually 4 FORMCHECKBOX  Always 12. In the last 12 months, how often did the dentists or dental staff explain what they were doing while treating you? 1 FORMCHECKBOX  Never 2 FORMCHECKBOX  Sometimes 3 FORMCHECKBOX  Usually 4 FORMCHECKBOX  Always 13. In the last 12 months, how often were your dental appointments as soon as you wanted? 1 FORMCHECKBOX  Never 2 FORMCHECKBOX  Sometimes 3 FORMCHECKBOX  Usually 4 FORMCHECKBOX  Always 14. If you needed to see a dentist right away because of a dental emergency in the last 12 months, did you get to see a dentist as soon as you wanted? 0 FORMCHECKBOX  I did not have a dental emergency in the last 12 months 1 FORMCHECKBOX  Definitely yes 2 FORMCHECKBOX  Somewhat yes 3 FORMCHECKBOX  Somewhat no 4 FORMCHECKBOX  Definitely no 15. If you tried to get an appointment for yourself with a dentist who specializes in a particular type of dental care (such as root canals or gum disease) in the last 12 months, how often did you get an appointment as soon as you wanted? 0 FORMCHECKBOX  I did not try to get an appointment with a specialist dentist for myselfin the last 12 months 1 FORMCHECKBOX  Never 2 FORMCHECKBOX  Sometimes 3 FORMCHECKBOX  Usually 4 FORMCHECKBOX  Always 16. In the last 12 months, how often did you have to spend more than 15 minutes in the waiting room before you saw someone for your appointment? 1 FORMCHECKBOX  Never ( If Never, go to #18 2 FORMCHECKBOX  Sometimes 3 FORMCHECKBOX  Usually 4 FORMCHECKBOX  Always 17. If you had to spend more than 15 minutes in the waiting room before you saw someone for your appointment, how often did someone tell you why there was a delay or how long the delay would be? 1 FORMCHECKBOX  Never 2 FORMCHECKBOX  Sometimes 3 FORMCHECKBOX  Usually 4 FORMCHECKBOX  Always 18. Using any number from 0 to 10, where 0 is the worst dental care possible and 10 is the best dental care possible, what number would you use to rate all of the dental care you personally received in the last 12 months?  FORMCHECKBOX  0 Worst dental care possible  FORMCHECKBOX  1  FORMCHECKBOX  2  FORMCHECKBOX  3  FORMCHECKBOX  4  FORMCHECKBOX  5  FORMCHECKBOX  6  FORMCHECKBOX  7  FORMCHECKBOX  8  FORMCHECKBOX  9  FORMCHECKBOX  10 Best dental care possible Your Dental Plan The next set of questions asks about your dental plan. For these questions, answer only about your dental plan. 19. In the last 12 months, how often did your dental plan cover all of the services you thought were covered? 1 FORMCHECKBOX  Never 2 FORMCHECKBOX  Sometimes 3 FORMCHECKBOX  Usually 4 FORMCHECKBOX  Always 20. In the last 12 months, did your dental plan cover what you and your family needed to get done? 1 FORMCHECKBOX  Definitely yes 2 FORMCHECKBOX  Somewhat yes 3 FORMCHECKBOX  Somewhat no 4 FORMCHECKBOX  Definitely no 21. In the last 12 months, did you try to find out how your dental plan works by calling their 800 number, visiting their website, or reading printed materials? 1 FORMCHECKBOX  Yes 2 FORMCHECKBOX  No ( If No, go to #23 22. In the last 12 months, how often did the 800 number, written materials, or website provide the information you wanted? 1 FORMCHECKBOX  Never 2 FORMCHECKBOX  Sometimes 3 FORMCHECKBOX  Usually 4 FORMCHECKBOX  Always 23. In the last 12 months, did you use any information from the dental plan to help you find a new dentist? 1 FORMCHECKBOX  Yes 2 FORMCHECKBOX  No ( If No, go to #26 24. Did this information help you find a dentist you were happy with? 1 FORMCHECKBOX  Definitely yes 2 FORMCHECKBOX  Somewhat yes 3 FORMCHECKBOX  Somewhat no 4 FORMCHECKBOX  Definitely no 25. Using any number from 0 to 10, where 0 is extremely difficult and 10 is extremely easy, what number would you use to rate how easy it was for you to find a dentist?  FORMCHECKBOX  0 Extremely difficult  FORMCHECKBOX  1  FORMCHECKBOX  2  FORMCHECKBOX  3  FORMCHECKBOX  4  FORMCHECKBOX  5  FORMCHECKBOX  6  FORMCHECKBOX  7  FORMCHECKBOX  8  FORMCHECKBOX  9  FORMCHECKBOX  10 Extremely easy 26. In the last 12 months, did you try to get information or help from your dental plan s customer service? 1 FORMCHECKBOX  Yes 2 FORMCHECKBOX  No ( If No, go to #29 27. In the last 12 months, how often did your dental plans customer service give you the information or help you needed? 1 FORMCHECKBOX  Never 2 FORMCHECKBOX  Sometimes 3 FORMCHECKBOX  Usually 4 FORMCHECKBOX  Always 28. In the last 12 months, how often did your dental plans customer service staff treat you with courtesy and respect? 1 FORMCHECKBOX  Never 2 FORMCHECKBOX  Sometimes 3 FORMCHECKBOX  Usually 4 FORMCHECKBOX  Always 29. Using any number from 0 to 10, where 0 is the worst dental plan possible and 10 is the best dental plan possible, what number would you use to rate your dental plan?  FORMCHECKBOX  0 Worst dental plan possible  FORMCHECKBOX  1  FORMCHECKBOX  2  FORMCHECKBOX  3  FORMCHECKBOX  4  FORMCHECKBOX  5  FORMCHECKBOX  6  FORMCHECKBOX  7  FORMCHECKBOX  8  FORMCHECKBOX  9  FORMCHECKBOX  10 Best dental plan possible 30. Would you say that your dental plan is worth the cost? 1 FORMCHECKBOX  Definitely yes 2 FORMCHECKBOX  Somewhat yes 3 FORMCHECKBOX  Somewhat no 4 FORMCHECKBOX  Definitely no 31. Would you recommend this dental plan to people who want to join? 1 FORMCHECKBOX  Definitely yes 2 FORMCHECKBOX  Probably yes 3 FORMCHECKBOX  Probably no 4 FORMCHECKBOX  Definitely no About You 32. 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Are you male or female? 1 FORMCHECKBOX  Male 2 FORMCHECKBOX  Female 35. What is the highest grade or level of school that you have completed? 1 FORMCHECKBOX  8th grade or less 2 FORMCHECKBOX  Some high school, but did not graduate 3 FORMCHECKBOX  High school graduate or GED 4 FORMCHECKBOX  Some college or 2-year degree 5 FORMCHECKBOX  4-year college graduate 6 FORMCHECKBOX  More than 4-year college degree 36. Are you of Hispanic or Latino origin or descent? 1 FORMCHECKBOX  Yes, Hispanic or Latino 2 FORMCHECKBOX  No, not Hispanic or Latino 37. What is your race? Please mark one or more. 1 FORMCHECKBOX  White 2 FORMCHECKBOX  Black or African-American 3 FORMCHECKBOX  Asian 4 FORMCHECKBOX  Native Hawaiian or other Pacific Islander 5 FORMCHECKBOX  American Indian or Alaska Native 6 FORMCHECKBOX  Other 38. Did someone help you complete this survey? 1 FORMCHECKBOX  Yes 2 FORMCHECKBOX  No ( Thank you. Please return the completed survey in the postage-paid envelope. 39. How did that person help you? Mark one or more. 1 FORMCHECKBOX  Read the questions to me 2 FORMCHECKBOX  Wrote down the answers I gave 3 FORMCHECKBOX  Answered the questions for me 4 FORMCHECKBOX  Translated the questions into my language 5 FORMCHECKBOX  Helped in some other way Thank you. Please return the completed survey in the postage-paid envelope.     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