CAHPS® Hospice Survey

Survey Instruments
     

The CAHPS Hospice Survey Instruments posted below have been approved by OMB (mail and telephone). To view or download a PDF version of the survey, click on the links below.

 CAHPS Hospice Survey Mail Materials V3.0

  • Click here to view or download the English mail survey materials (Updated 12/19/2016)
  • Click here to view or download the Spanish mail survey materials (Updated 12/19/2016)
  • Click here to view or download the Traditional Chinese mail survey materials (Updated 05/26/2017)
  • Click here to view or download the Simplified Chinese mail survey materials (Updated 05/26/2017)
  • Click here to view or download the Russian mail survey materials (Updated 12/19/2016)
  • Click here to view or download the Portuguese mail survey materials (Updated 12/19/2016)
  • Click here to view or download the Vietnamese mail survey materials (Updated 12/19/2016)
  • Click here to view or download the Polish mail survey materials (Updated 12/19/2016)
  • Click here to view or download the Korean mail survey materials (Updated 12/19/2016)

CAHPS Hospice Survey Telephone Scripts V3.0

  • Click here to view or download the English Telephone Script (Updated 12/19/2016)
  • Click here to view or download the Spanish Telephone Script (Updated 12/19/2016)

Consent to Share Responses Supplemental Question

One supplemental question must be included in the mail and telephone questionnaire if the hospice wishes to view the survey responses linked to respondents’ name and other identifying information. The survey question, referred to as the Consent to Share Responses, must be printed in the mail questionnaire and included in the telephone questionnaire. The respondent must check the “Yes” response option in the mail questionnaire or answer “Yes” to the question during the telephone interview for the survey vendor to provide the hospice with the respondent’s answers linked to the respondent’s name and identifying information. The question is typically placed at the end of the questionnaire or interview, as the last question.

The Consent to Share Responses language for the mail questionnaire is as follows:

The hospice that provided care to your family member may want to review your answers so that they can decide how to address any concerns that you have. We will not share your answers to this survey linked to your name unless you give your permission for this information to be shared with the hospice.

Do you give your permission to provide your answers to this survey linked to your name to the hospice?

     0  Yes, I give my permission to share my name and survey responses with the hospice.     

     0  No, I do not give permission to share my name and survey responses with the hospice.

 The Consent to Share Responses language for the telephone interview script is as follows:

The hospice that provided care to your family member may want to review your answers so that they can decide how to address any concerns that you have. We will not share your answers to this survey linked to your name unless you give your permission for this information to be shared with the hospice.

Do you give your permission to provide your answers to this survey linked to your name to the hospice?

     0  Yes

     0  No

 The Consent to Share Responses supplemental question text is available for download below:

  • Click here to view or download the English Consent to Share Responses supplemental question (Updated 01/30/2017)
  • Click here to view or download the Spanish Consent to Share Responses supplemental question (Updated 01/30/2017)
  • Click here to view or download the Traditional Chinese Consent to Share Responses supplemental question
  • Click here to view or download the Simplified Chinese Consent to Share Responses supplemental question
  • Click here to view or download the Russian Consent to Share Responses supplemental question
  • Click here to view or download the Portuguese Consent to Share Responses supplemental question
  • Click here to view or download the Vietnamese Consent to Share Responses supplemental question
  • Click here to view or download the Polish Consent to Share Responses supplemental question
  • Click here to view or download the Korean Consent to Share Responses supplemental question

 

This page was last modified on 05/26/2017