A
Form
Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX
Demonstration of Health Literacy Universal Precautions Toolkit
This document identifies the CAHPS items for that will be collected for a random sample of patients from two practices. Data will be collected by mail and phone administration.
Your Provider
Our records show that you got care from the provider named below in the last 12 months.
Name of provider label goes here
Is that right?
1 Yes
2 No → If No, go to question 33
The questions in this survey will refer to the provider named in Question 1 as “this provider.” Please think of that provider as you answer the survey.
Is this the provider you usually see if you need a check-up, want advice about a health problem, or get sick or hurt?
1 Yes
2 No
Your Care From This Provider in the Last 6 Months
In the last 6 months, how often did this provider explain things in a way that was easy to understand?
1 Never
2 Sometimes
3 Usually
4 Always
Public reporting burden for this
collection of information is estimated to average 12 minutes per
response, the estimated time required to participate in this
survey. An agency may not conduct or sponsor, and a person is
not required to respond to, a collection of information unless it
displays a currently valid OMB control number. Send
comments regarding this burden estimate or any other aspect of
this collection of information, including suggestions for reducing
this burden, to: AHRQ Reports Clearance Officer Attention: PRA,
Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room
# 5036, Rockville, MD 20850.
4. In the last 6 months, how often did this provider use medical words you did not understand?
1 Never
2 Sometimes
3 Usually
4 Always
5. In the last 6 months, how often did this provider talk too fast when talking with you?
1 Never
2 Sometimes
3 Usually
4 Always
6. In the last 6 months, how often did this provider use pictures, drawings, models, or videos to explain things to you?
1 Never
2 Sometimes
3 Usually
4 Always
7. In the last 6 months, how often did this provider listen carefully to you?
1 Never
2 Sometimes
3 Usually
4 Always
8. In the last 6 months, how often did this provider interrupt you when you were talking?
1 Never
2 Sometimes
3 Usually
4 Always
9. In the last 6 months, how often did this provider show interest in your questions and concerns?
1 Never
2 Sometimes
3 Usually
4 Always
10. In the last 6 months, how often did this provider answer all your questions to your satisfaction?
1 Never
2 Sometimes
3 Usually
4 Always
11. In the last 6 months, how often did this provider give you all the information you wanted about your health?
1 Never
2 Sometimes
3 Usually
4 Always
12. In the last 6 months, how often did this provider encourage you to talk about all your health questions or concerns?
1 Never
2 Sometimes
3 Usually
4 Always
13. In the last 6 months, did you see this provider for a specific illness or for a specific illness or for any health condition?
1 Yes
2 No → If No, go to question 17
14. In the last 6 months, how often did this provider give you instructions about what to do to take care of this illness or health condition?
1 Yes
2 No → If No, go to question 17
15. In the last 6 months, how often were these instructions easy to understand?
1 Never
2 Sometimes
3 Usually
4 Always
16. In the last 6 months, how often did this provider ask you to describe how you were going to follow these instructions?
1 Never
2 Sometimes
3 Usually
4 Always
17. In the last 6 months, how often did this provider show respect for what you had to say?
1 Never
2 Sometimes
3 Usually
4 Always
18. In the last 6 months, how often did this provider spend enough time with you?
1 Never
2 Sometimes
3 Usually
4 Always
19. In the last 6 months, did this provider prescribe any new medicines or change how much medicine you should take?
1 Yes
2 No → If No, go to question 27
20. In the last 6 months, did this provider give you instructions about how to take your medicines?
1 Yes
2 No → If No, go to question 22
21. In the last 6 months, how often were these instructions about how to take your medicines easy to understand?
1 Never
2 Sometimes
3 Usually
4 Always
22. In the last 6 months, did this provider explain the possible side effects of your medicines?
1 Yes
2 No → If No, go to question 24
23. In the last 6 months, how often were these explanations easy to understand?
1 Never
2 Sometimes
3 Usually
4 Always
24. In the last 6 months, other than a prescription, did this provider give you written information or write down information about how to take your medicines?
1 Yes
2 No → If No, go to question 26
25. In the last 6 months, how often was the written information you were given easy to understand?
1 Never
2 Sometimes
3 Usually
4 Always
26. In the last 6 months, how often did this provider suggest ways to help you remember to take your medicines?
1 Never
2 Sometimes
3 Usually
4 Always
27. In the last 6 months, did this provider order a blood test, x-ray or other test for you?
1 Yes
2 No → If No, go to question 30
28. In the last 6 months, when this provider ordered a blood test, x-ray or other test for you, how often did someone from this provider's office follow up to give you those results?
1 Never
2 Sometimes
3 Usually
4 Always
29. In the last 6 months, how often were the results of your blood test, x-ray or other test easy to understand?
1 Never
2 Sometimes
3 Usually
4 Always
30. Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?
0 Worst provider possible
1
2
3
4
5
6
7
8
9
10 Best provider possible
31. In the last 6 months, did you have to sign any forms at this provider’s office?
1 Yes
2 No → If No, go to question 33
32. In the last 6 months, how often did someone explain the purpose of a form before you signed it?
1 Never
2 Sometimes
3 Usually
4 Always
33. In the last 6 months, did you fill out any forms at this provider’s office?
1 Yes
2 No → If No, go to question 36
34. In the last 6 months, how often were you offered help in filling out a form at this provider’s office?
1 Never
2 Sometimes
3 Usually
4 Always
35. In the last 6 months, how often were the forms that you got at this provider’s office easy to fill out?
1 Never
2 Sometimes
3 Usually
4 Always
About You
36. What is your age?
1 18 to 24
2 25 to 34
3 35 to 44
4 45 to 54
5 55 to 64
6 65 to 74
7 75 or older
37. Are you male or female?
1 Male
2 Female
38. What is the highest grade or level of school that you have completed?
1 8th grade or less
2 Some high school, but did not graduate
3 High school graduate or GED
4 Some college or 2-year degree
5 4-year college graduate
6 More than 4-year college degree
39. Are you of Hispanic or Latino origin or descent?
1 Yes, Hispanic or Latino
2 No, not Hispanic or Latino
40. What is your race? Please mark one or more.
1 White
2 Black or African American
3 Asian
4 Native Hawaiian or Other Pacific Islander
American Indian or Alaskan Native
Other
41. Did someone help you complete this survey?
Yes
No You are finished filling out this survey. Thank you.
42. How did that person help you? (Please mark all that apply)
Read the questions to me
Wrote down the answers I gave
Answered the questions for me
Translated the questions into my language
Helped in some other way (please specify: _______________________________________)
| File Type | application/msword |
| Author | Brega, Angela |
| Last Modified By | DHHS |
| File Modified | 2012-05-22 |
| File Created | 2012-05-22 |