The CAHPS Hospice Survey Data Warehouse is maintained by the RAND Corporation. All hospices must have a user account in the CAHPS Hospice Survey Data Warehouse in order to monitor data submission activities.

Provide contact information below for your hospice’s Data Administrator and Back-up Data Administrator. Complete contact information is required to authorize a user account.  

Your form must be submitted one calendar quarter (90 days) prior to the first time your hospice's data will be submitted to the CAHPS Hospice Survey Data Warehouse.

Please note: By submitting a new form, your organization is indicating a change to its Data Administrator and/or Back-up Data Administrator.  Administrators listed on prior Data Warehouse Access Forms will no longer have access to the Data Warehouse.

Unique Report ID : 1316

1. Hospice Information

CCN (Must be 6-characters, no hyphens) * CCN is required. The first position must be an alphanumeric. Only the first position can be alphanumeric. Cannot have any hyphens. The third position must be a 1. Too few characters. Must be 6 characters Too many characters. Must be 6 characters

Hospice Name * Hospice Name is required.

2. Data Administrator

First Name * First Name is required.

Last Name * Last Name is required.

Phone Number * Phone Number is required.

Phone Extension

Email * Email is required.

3. Back-up Data Administrator

First Name * First Name is required.

Last Name * Last Name is required.

Phone Number * Phone Number is required.

Phone Extension

Email * Email is required.

4. Additional Data Administrator (Optional)

First Name

Last Name

Phone Number

Phone Extension

Email

5. Acknowledgement

Note: A separate CAHPS Hospice Survey Data Warehouse Access Form must be submitted for each hospice CCN.

CCN

Hospice Name

In this role the Authorized Hospice Data Administrator will be responsible for:

1) Designating an individual within the hospice organization to serve as the main point of contact with the CAHPS Hospice Survey Project Team.

2) Notifying the CAHPS Hospice Survey Project Team if my role as the CAHPS Hospice Survey Data Administrator for the hospice will no longer be valid and identifying my successor by submitting a new Data Warehouse Access Form.

By checking this box, I certify that I am authorized to complete this form on behalf of this hospice agency.* Checkbox is required.

Authorized Administrator Name * Authorized Administrator Name is required.

Authorized Administrator Signature

Date

By checking this box, I agree that the electronic signature is the equivalent of my manual signature on this agreement.* Checkbox is required.

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Note: Please print completed Data Warehouse Access form before submitting.

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