Form 1 NRC NIH Inpatient Pediatric Survey

B

OMB No. 0925-0648 Expiration Date: 03/2018

Please use the enclosed envelope and
mail the completed survey to:
NRC Health
Survey Processing Center
PO BOX 82660
Lincoln, NE 68501-2660
1-800-733-6714

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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: NIH,
Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0648). Do not return the completed form to
this address.
SURVEY INSTRUCTIONS

* Answer each question by completely filling in the circle 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:
d Yes > Go
E No

to Question 1

Please answer the questions about the child
and hospital named in the cover letter. Do not
include any other hospital stays in your
answers.

5. During the first day of this hospital stay, were
you asked to list or review all of the prescription
medicines your child was taking at home?47942
1 Yes, definitely
E
2 Yes, somewhat
E
3 No
E

WHEN YOUR CHILD WAS ADMITTED TO THIS
HOSPITAL
1. Was your child born during this hospital stay?47938
1 Yes > Go to Question 14
E
2 No
E
2. For this hospital stay, was your child admitted
through this hospital's Emergency Room?47939
1 Yes
E
2 No > Go to Question 5
E
3. Were you in this hospital's Emergency Room
with your child?52537
1 Yes
E
2 No > Go to Question 5
E

B

4. While your child was in this hospital's
Emergency Room, were you kept informed
about what was being done for your child?52538
1 Yes, definitely
E
2 Yes, somewhat
E
3 No
E

*001AMD14*

6. During the first day of this hospital stay, were
you asked to list or review all of the vitamins,
herbal medicines, and over-the-counter
medicines your child was taking at home?47943
1 Yes, definitely
E
2 Yes, somewhat
E
3 No
E
YOUR CHILD'S CARE AFTER ADMISSION TO
THIS HOSPITAL
Do not include care received in the Emergency
Room for the rest of the survey.
7. Is your child able to talk with nurses and
doctors about his or her health care?47944
1 Yes
E
2 No > Go to Question 14
E

*001AMD14*

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YOUR CHILD'S EXPERIENCE WITH NURSES

YOUR EXPERIENCE WITH NURSES

The next questions ask about your child's
experience during this hospital stay. You will
be asked about your own experience during
this hospital stay in later questions.

14. During this hospital stay, how often did your
child's nurses listen carefully to you?47953
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

8. During this hospital stay, how often did your
child's nurses listen carefully to your child?47945
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

15. During this hospital stay, how often did your
child's nurses explain things to you in a way
that was easy to understand?47954
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

9. During this hospital stay, how often did your
child's nurses explain things in a way that was
easy for your child to understand?47946
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

16. During this hospital stay, how often did your
child's nurses treat you with courtesy and
respect?47955
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

10. During this hospital stay, how often did your
child's nurses encourage your child to ask
questions?47948
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

YOUR EXPERIENCE WITH DOCTORS

YOUR CHILD'S EXPERIENCE WITH DOCTORS
11. During this hospital stay, how often did your
child's doctors listen carefully to your child?47949
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
12. During this hospital stay, how often did your
child's doctors explain things in a way that was
easy for your child to understand?47950
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

B

13. During this hospital stay, how often did your
child's doctors encourage your child to ask
questions?47952
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

*001AMD25*

17. During this hospital stay, how often did your
child's doctors listen carefully to you?47956
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
18. During this hospital stay, how often did your
child's doctors explain things to you in a way
that was easy to understand?47957
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
19. During this hospital stay, how often did your
child's doctors treat you with courtesy and
respect?47958
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

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YOUR EXPERIENCE WITH PROVIDERS

YOUR CHILD'S CARE IN THIS HOSPITAL

20. A provider in the hospital can be a doctor,
nurse, nurse practitioner, or physician
assistant. During this hospital stay, how often
were you given as much privacy as you wanted
when discussing your child's care with
providers?47964
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

26. During this hospital stay, did you or your child
ever press the call button?47969
1 Yes
E
2 No > Go to Question 28
E

21. Things that a family might know best about a
child include how the child usually acts, what
makes the child comfortable, and how to calm
the child's fears. During this hospital stay, did
providers ask you about these types of things?47963
1 Yes, definitely
E
2 Yes, somewhat
E
3 No
E
22. During this hospital stay, how often did
providers talk with and act toward your child in a
way that was right for your child's age?47959
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
23. During this hospital stay, how often did
providers keep you informed about what was
being done for your child?47961
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
24. Tests in the hospital can include things like
blood tests and x-rays. During this hospital
stay, did your child have any tests?47966
1 Yes
E
2 No > Go to Question 26
E

B

25. How often did providers give you as much
information as you wanted about the results of
these tests?47967
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

*001AMD36*

27. After pressing the call button, how often was
help given as soon as you or your child wanted
it?47970
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
28. During this hospital stay, was your child given
any medicine?47973
1 Yes
E
2 No > Go to Question 30
E
29. Before giving your child any medicine, how
often did providers or other hospital staff check
your child's wristband or confirm his or her
identity in some other way?47974
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
30. Mistakes in your child's health care can include
things like giving the wrong medicine or doing
the wrong surgery. During this hospital stay, did
providers or other hospital staff tell you how to
report if you had any concerns about mistakes
in your child's health care?47975
1 Yes, definitely
E
2 Yes, somewhat
E
3 No
E
31. During this hospital stay, did your child have
pain that needed medicine or other treatment?47976
1 Yes
E
2 No > Go to Question 33
E
32. During this hospital stay, did providers or other
hospital staff ask about your child's pain as
often as your child needed?49005
1 Yes, definitely
E
2 Yes, somewhat
E
3 No
E

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THE HOSPITAL ENVIRONMENT
33. During this hospital stay, how often were your
child's room and bathroom kept clean?47994
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
34. During this hospital stay, how often was the
area around your child's room quiet at night?47995
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E
35. Hospitals can have things like toys, books,
mobiles, and games for children from newborns
to teenagers. During this hospital stay, did the
hospital have things available for your child that
were right for your child's age?49007
1 Yes, definitely
E
2 Yes, somewhat
E
3 No
E
WHEN YOUR CHILD LEFT THIS HOSPITAL
36. As a reminder, a provider in the hospital can be
a doctor, nurse, nurse practitioner, or physician
assistant. Before your child left the hospital,
did a provider ask you if you had any concerns
about whether your child was ready to leave?47999
1 Yes, definitely
E
2 Yes, somewhat
E
3 No
E
37. Before your child left the hospital, did a
provider talk with you as much as you wanted
about how to care for your child's health after
leaving the hospital?48000
1 Yes, definitely
E
2 Yes, somewhat
E
3 No
E

*001AMD47*

40. Before your child left the hospital, did a
provider or hospital pharmacist explain in a way
that was easy to understand about possible side
effects of these new medicines?48001
1 Yes, definitely
E
2 Yes, somewhat
E
3 No
E
41. A child's regular activities can include things
like eating, bathing, going to school, or playing
sports. Before your child left the hospital, did a
provider explain in a way that was easy to
understand when your child could return to his
or her regular activities?49009
1 Yes, definitely
E
2 Yes, somewhat
E
3 No
E
42. Before your child left the hospital, did a
provider explain in a way that was easy to
understand what symptoms or health problems
to look out for after your child left the hospital?49008
1 Yes, definitely
E
2 Yes, somewhat
E
3 No
E
43. Before your child left the hospital, did you get
information in writing about what symptoms or
health problems to look out for after your child
left the hospital?49010
1 Yes, definitely
E
2 Yes, somewhat
E
3 No
E

38. Before your child left the hospital, did a
provider tell you that your child should take any
new medicine that he or she had not been taking
when this hospital stay began?48003
1 Yes
E
2 No > Go to Question 41
E

B

39. Before your child left the hospital, did a
provider or hospital pharmacist explain in a way
that was easy to understand how your child
should take these new medicines after leaving
the hospital?48002
1 Yes, definitely
E
2 Yes, somewhat
E
3 No
E

YOUR TEEN'S CARE IN THIS HOSPITAL
44. During this hospital stay, was your child 13
years old or older?48008
1 Yes
E
2 No > Go to Question 48
E

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45. During this hospital stay, how often did
providers involve your child in discussions
about his or her health care? 48009
1 Never
E
2 Sometimes
E
3 Usually
E
4 Always
E

50. Is there anything else you would like to say
about the care your child received during this
hospital stay? Please print:

46. Before your child left the hospital, did a
provider ask your child if he or she had any
concerns about whether he or she was ready to
leave?48010
1 Yes, definitely
E
2 Yes, somewhat
E
3 No
E
47. Before your child left the hospital, did a
provider talk with your child about how to take
care of his or her health after leaving the
hospital? 48011
1 Yes, definitely
E
2 Yes, somewhat
E
3 No
E

ABOUT YOUR CHILD
51. In general, how would you rate your child's
overall health?48014
1 Excellent
E
2 Very good
E
3 Good
E
4 Fair
E
5 Poor
E

OVERALL RATING OF THIS HOSPITAL
As a reminder, please answer the questions
about the child and hospital named in the
cover letter. Do not include any other hospital
stays in your answers.

52. What is your child's age?52539
1 Less than 1 year old
E
2 __________ YEARS OLD (write in)
E

48. Using any number from 0 to 10, where 0 is the
worst hospital possible and 10 is the best
hospital possible, what number would you use
to rate this hospital during your child's stay?48012
0 0 Worst hospital possible
E
1 1
E
2 2
E
3 3
E
4 4
E
5 5
E
6 6
E
7 7
E
8 8
E
9 9
E
1E
0 10 Best hospital possible

B

49. Would you recommend this hospital to your
friends and family?48013
1 Definitely no
E
2 Probably no
E
3 Probably yes
E
4 Definitely yes
E

*001AMD58*

53. Is your child male or female?52540
1 Male
E
2 Female
E
54. Is your child of Hispanic or Latino origin or
descent?52541
1 Yes, Hispanic or Latino
E
2 No, not Hispanic or Latino
E
55. What is your child's race? Please mark one or
more.52542
1 White
F
2 Black or African American
F
3 Asian
F
4 Native Hawaiian or other Pacific Islander
F
5 American Indian or Alaska Native
F
6 Other
F

*001AMD58*

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ABOUT YOU

62. How did that person help you? Please mark
one or more.54239
1 Read the questions to me
F
2 Wrote down the answers I gave
F
3 Answered the questions for me
F
4 Translated the questions into my
F
language
5 Helped in some other way (please
F
print):__________________

56. How are you related to the child?48017
1 Mother
E
2 Father
E
3 Grandmother
E
4 Grandfather
E
5 Other relative or legal guardian
E
6 Someone else (Please print:
E
________________________________)
57. What is your age?48018
1 Under 18
E
2 18-24
E
3 25-34
E
4 35-44
E
5 45-54
E
6 55-64
E
7 65-74
E
8 75 or older
E

THANK YOU
Please return the completed survey in the
postage-paid envelope.

58. What is the highest grade or level of school that
you have completed?49080
1 8th grade or less
E
2 Some high school, but did not graduate
E
3 High school graduate or GED
E
4 Some college or 2-year degree
E
5 4-year college graduate
E
6 More than 4-year college degree
E
59. What is your preferred language?47988
1 English
E
2 Spanish
E
3 Chinese
E
4 Vietnamese
E
5 Korean
E
6 Russian
E
7 Other language (Please print:
E
_____________________________)
60. During your child's hospital stay, how much of
the time were you at the hospital?48020
1 None of the time
E
2 A little of the time
E
3 Some of the time
E
4 Most of the time
E
5 All or nearly all of the time
E

B

61. Did someone help you complete this survey?52543
1 Yes
E
2 No > Thank you. Please return the
E
completed survey in the postage-paid
envelope.

*001AMD69*

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