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CAHPS� Nursing Home Survey
Version: Discharged Resident Instrument
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 discharged-resident-653a.doc
Released: April 18, 2011Instructions for Front Cover
Replace the cover of this document with your own front cover. Include a user-friendly title, your own logo, and the name of the nursing home.
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 don抰 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 health care you get.
What To Do When You抮e 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 team抯 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
Please answer the questions in this survey about your stay in the nursing home named on the cover. Do not include any other nursing home stays in your answers.
1. For the following questions, use any number from 0 to 10, where 0 is the worst possible and 10 is the best possible.
What number would you use to rate the food at the nursing home?
FORMCHECKBOX 0 Worst possible
FORMCHECKBOX 1
FORMCHECKBOX 2
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FORMCHECKBOX 10 Best possible
2. Did you ever eat in the dining room?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No ( If No, go to #4
3. When you ate in the dining room in the nursing home, what number would you use to rate how much you enjoyed mealtimes?
FORMCHECKBOX 0 Worst possible
FORMCHECKBOX 1
FORMCHECKBOX 2
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4. What number would you use to rate how comfortable the temperature was in the nursing home?
FORMCHECKBOX 0 Worst possible
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FORMCHECKBOX 10 Best possible
5. Think about all the different areas of the nursing home. What number would you use to rate how clean the nursing home was?
FORMCHECKBOX 0 Worst possible
FORMCHECKBOX 1
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FORMCHECKBOX 7
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FORMCHECKBOX 10 Best possible
6. What number would you use to describe how safe and secure you felt in the nursing home?
FORMCHECKBOX 0 Worst possible
FORMCHECKBOX 1
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FORMCHECKBOX 10 Best possible
7. Think about all the different kinds of medicine that help with aches or pain. This includes medicine prescribed by a doctor, as well as aspirin and Tylenol.
When you were in the nursing home, did you ever take any medicine to help with aches or pain?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No ( If No, go to #10
8. Thinking about when you were in the nursing home, what number would you use to rate how well the medicine to help with aches or pain worked?
FORMCHECKBOX 0 Worst possible
FORMCHECKBOX 1
FORMCHECKBOX 2
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9. What number would you use to rate how well the nursing home staff helped you when you had pain?
FORMCHECKBOX 0 Worst possible
FORMCHECKBOX 1
FORMCHECKBOX 2
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FORMCHECKBOX 4
FORMCHECKBOX 5
FORMCHECKBOX 6
FORMCHECKBOX 7
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FORMCHECKBOX 10 Best possible
10. What number would you use to rate how quickly the nursing home staff came when you called for help?
FORMCHECKBOX 0 Worst possible
FORMCHECKBOX 1
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FORMCHECKBOX 10 Best possible
11. When you were in the nursing home, did the staff help you get dressed, take a shower, or go to the toilet?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No ( If No, go to #13
12. What number would you use to rate how gentle the nursing home staff were when they helped you?
FORMCHECKBOX 0 Worst possible
FORMCHECKBOX 1
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13. What number would you use to rate how respectful the nursing home staff were to you?
FORMCHECKBOX 0 Worst possible
FORMCHECKBOX 1
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14. What number would you use to rate how well the nursing home staff listened to you?
FORMCHECKBOX 0 Worst possible
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15. What number would you use to rate how well the nursing home staff explained things in a way that was easy to understand?
FORMCHECKBOX 0 Worst possible
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16. Overall, what number would you use to rate the care you got from the nursing home staff?
FORMCHECKBOX 0 Worst possible
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FORMCHECKBOX 10 Best possible
17. When you were in the nursing home, did you have any special therapy, such as physical, occupational, or speech therapy?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No ( If No, go to #19
18. Thinking about when you were in the nursing home, what number would you use to rate the special therapy you got?
FORMCHECKBOX 0 Worst possible
FORMCHECKBOX 1
FORMCHECKBOX 2
FORMCHECKBOX 3
FORMCHECKBOX 4
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FORMCHECKBOX 8
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FORMCHECKBOX 10 Best possible
19. Overall, what number would you use to rate the nursing home?
FORMCHECKBOX 0 Worst possible
FORMCHECKBOX 1
FORMCHECKBOX 2
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FORMCHECKBOX 5
FORMCHECKBOX 6
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D�h��h�� h^I45�h^I4h��5�(�>�>�>�?@6@^@咢瓳諤兀&ANAvA糀続BB圔癇谺C(CPCxC燙菴�������������������������gd&]Ngd&]N$$gd(s� gd(s�gd奻�gd奻�.@0@6@8@T@V@X@^@`@|@~@€@咢園ˊ瓳癅藹蜙蠤諤谸鬇鯜鳣兀AAA A&A(ADAFAHANAPAlAnApAvAxA擜朅楢濧燗続腁黧黧梓篦筝黧黧吟篦笄黧黧槛篦蟊黧黧篦鬀黧黧愾篦髨h[�h��5��j鴖h&]NU�j剆h&]NU�jsh&]NU�j渞h&]NU�j(rh&]NU�j磓h&]NU�j@qh&]NU�j蘰h&]NU�jXph&]NUh&]Njh&]NU2腁艫$B�@�聬鋹鎼钀�������2�4�6�>�矜哝哐孢孢面哝吡叱孢孢棐妴{妴t拪唅妴�j躽h奻�Uh&]Nh奻��jhyh奻�Uh奻�jh奻�U h^jEH*h$mh��h�� h^I45�h^I4h��5�h&]N�j魓h[�h&]NUU�j€xh[�h&]NU�jxh[�h&]NUh[�h&]Njh[�h&]NU�j榳h[�h&]NU(菴餋6�8�鋹�>�x�z�H�v�軖迴d�挀鎿钃爺螖鷶4����������������������gd^jE$$gd^jEgd��gd�� gd^I4gd奻�gd奻�$$gd(s� gd(s�gd&]Ngd&]N$$gd(s�ECKBOX 10 Best possible
20. When you were in the nursing home, was the area around your room quiet at night?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
3 FORMCHECKBOX Sometimes
21. When you were in the nursing home, were you bothered by noise in the nursing home during the day?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
3 FORMCHECKBOX Sometimes
22. When you were in the nursing home, did you have any visitors?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No ( If No, go to #24
23. When you had visitors in the nursing home, could you find a place to visit in private?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
3 FORMCHECKBOX Sometimes
24. When you were in the nursing home, did you visit a doctor for medical care outside the nursing home?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
3 FORMCHECKBOX Sometimes
25. When you were in the nursing home, did you visit a doctor for medical care inside the nursing home?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
3 FORMCHECKBOX Sometimes
26. When you were in the nursing home, could you turn yourself over in bed without help from another person?
1 FORMCHECKBOX Yes ( If Yes, go to #29
2 FORMCHECKBOX No
27. When you were in the nursing home, were you ever left sitting or laying in the same position so long that it hurt?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
3 FORMCHECKBOX Sometimes
28. When you were in the nursing home, were you able to move your arms to reach things that you wanted?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No ( If No, go to #31
3 FORMCHECKBOX Sometimes
29. We would like to find out about whether you could reach the things you needed in your room.
When you were in the nursing home, could you reach the call button by yourself?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
3 FORMCHECKBOX Sometimes
30. When you were in the nursing home, was there a pitcher of water or something to drink where you could reach it by yourself?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
3 FORMCHECKBOX Sometimes
31. When you were in the nursing home, did the staff help you dress, take a shower, or bathe?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No ( If No, go to #33
32. When you were in the nursing home, did the staff make sure you had enough personal privacy when you dressed, took a shower, or bathed?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
3 FORMCHECKBOX Sometimes
33. When you were in the nursing home, could you choose what time you went to bed?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
3 FORMCHECKBOX Sometimes
34. When you were in the nursing home, could you choose what clothes you wore?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
3 FORMCHECKBOX Sometimes
35. When you were in the nursing home, could you choose what activities you did there?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
3 FORMCHECKBOX Sometimes
36. When you were in the nursing home, were there enough organized activities for you to do on the weekends?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
3 FORMCHECKBOX Sometimes
37. When you were in the nursing home, were there enough organized activities for you to do during the week?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
3 FORMCHECKBOX Sometimes
38. Would you recommend the nursing home to others?
1 FORMCHECKBOX Definitely no
2 FORMCHECKBOX Probably no
3 FORMCHECKBOX Probably yes
4 FORMCHECKBOX Definitely yes
39. When you were in the nursing home, how often did you feel worried?
1 FORMCHECKBOX Often
2 FORMCHECKBOX Sometimes
3 FORMCHECKBOX Rarely
4 FORMCHECKBOX Never
40. When you were in the nursing home, how often did you feel happy?
1 FORMCHECKBOX Often
2 FORMCHECKBOX Sometimes
3 FORMCHECKBOX Rarely
4 FORMCHECKBOX Never
41. When you were in the nursing home, did you have a roommate?
1 FORMCHECKBOX Yes
2 FORMCHECKBOX No
42. Think about how you felt about your life when you were in the nursing home.
Use any number from 0 to 10, where 0 is the worst possible and 10 is the best possible. What number would you use to rate your life then?
FORMCHECKBOX 0 Worst possible
FORMCHECKBOX 1
FORMCHECKBOX 2
FORMCHECKBOX 3
FORMCHECKBOX 4
FORMCHECKBOX 5
FORMCHECKBOX 6
FORMCHECKBOX 7
FORMCHECKBOX 8
FORMCHECKBOX 9
FORMCHECKBOX 10 Best possible
43. In general, how would you rate your overall health?
1 FORMCHECKBOX Excellent
2 FORMCHECKBOX Very good
3 FORMCHECKBOX Good
4 FORMCHECKBOX Fair
5 FORMCHECKBOX Poor
44. Are you male or female?
1 FORMCHECKBOX Male
2 FORMCHECKBOX Female
45. In what year were you born?
Write in: �year
46. 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
47. Are you of Hispanic or Latino origin or descent?
1 FORMCHECKBOX Yes, Hispanic or Latino
2 FORMCHECKBOX No, not Hispanic or Latino
48. 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
49. Did someone help you complete this survey?
1 FORMCHECKBOX Yes ( If Yes, go to #50
2 FORMCHECKBOX No ( If No, please return the completed survey in the postage-paid envelope.
50. 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.
Nursing Home Survey Discharged Resident Instrument
Nursing Home Survey Discharged Resident Instrument
PAGE 8
Nursing Home Survey Discharged Resident Instrument
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