HCAHPS Survey
SURVEY INSTRUCTIONS
 You should only fill out this survey if you were the patient during the hospital stay
named in the cover letter. Do not fill out this survey if you were not the patient.
 Answer all the questions by checking 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:
 Yes
 No  If No, Go to Question 1
You may notice a number on the survey. This number is used to let us know if
you returned your survey so we don’t have to send you reminders.
Please note: Questions 1-25 in this survey are part of a national initiative to measure the quality
of care in hospitals. OMB #0938-0981
Please answer the questions in this survey
about your stay at the hospital named on
the cover letter. Do not include any other
hospital stays in your answers.
YOUR CARE FROM NURSES

ORDER NURSING COURSE WORKS HERE

  1. During this hospital stay, how often
    did nurses treat you with courtesy
    and respect?
    1 Never
    2 Sometimes
    3 Usually
    4 Always
  2. During this hospital stay, how often
    did nurses listen carefully to you?
    1 Never
    2 Sometimes
    3 Usually
    4 Always
  3. During this hospital stay, how often
    did nurses explain things in a way
    you could understand?
    1 Never
    2 Sometimes
    3 Usually
    4 Always
  4. During this hospital stay, after you
    pressed the call button, how often did
    you get help as soon as you wanted
    it?
    1 Never
    2 Sometimes
    3 Usually
    4 Always
    9 I never pressed the call button
    2 January 2018
    YOUR CARE FROM DOCTORS
  5. During this hospital stay, how often
    did doctors treat you with courtesy
    and respect?
    1 Never
    2 Sometimes
    3 Usually
    4 Always
  6. During this hospital stay, how often
    did doctors listen carefully to you?
    1 Never
    2 Sometimes
    3 Usually
    4 Always
  7. During this hospital stay, how often
    did doctors explain things in a way
    you could understand?
    1 Never
    2 Sometimes
    3 Usually
    4 Always
    THE HOSPITAL ENVIRONMENT
  8. During this hospital stay, how often
    were your room and bathroom kept
    clean?
    1 Never
    2 Sometimes
    3 Usually
    4 Always
  9. During this hospital stay, how often
    was the area around your room quiet
    at night?
    1 Never
    2 Sometimes
    3 Usually
    4 Always
    YOUR EXPERIENCES IN THIS HOSPITAL
  10. During this hospital stay, did you
    need help from nurses or other
    hospital staff in getting to the
    bathroom or in using a bedpan?
    1 Yes
    2 No  If No, Go to Question 12
  11. How often did you get help in getting
    to the bathroom or in using a bedpan
    as soon as you wanted?
    1 Never
    2 Sometimes
    3 Usually
    4 Always
  12. During this hospital stay, did you
    have any pain?
    1 Yes
    2 No  If No, Go to Question 15
  13. During this hospital stay, how often
    did hospital staff talk with you about
    how much pain you had?
    1 Never
    2 Sometimes
    3 Usually
    4 Always
  14. During this hospital stay, how often
    did hospital staff talk with you about
    how to treat your pain?
    1 Never
    2 Sometimes
    3 Usually
    4 Always
    January 2018 3
  15. During this hospital stay, were you
    given any medicine that you had not
    taken before?
    1 Yes
    2No  If No, Go to Question 18
  16. Before giving you any new medicine,
    how often did hospital staff tell you
    what the medicine was for?
    1 Never
    2 Sometimes
    3 Usually
    4 Always
  17. Before giving you any new medicine,
    how often did hospital staff describe
    possible side effects in a way you
    could understand?
    1 Never
    2 Sometimes
    3 Usually
    4 Always
    WHEN YOU LEFT THE HOSPITAL
  18. After you left the hospital, did you go
    directly to your own home, to
    someone else’s home, or to another
    health facility?
    1 Own home
    2 Someone else’s home
    3 Another health
    facility  If Another, Go to
    Question 21
  19. During this hospital stay, did doctors,
    nurses or other hospital staff talk with
    you about whether you would have
    the help you needed when you left the
    hospital?
    1 Yes
    2 No
  20. During this hospital stay, did you get
    information in writing about what
    symptoms or health problems to look
    out for after you left the hospital?
    1 Yes
    2 No
    OVERALL RATING OF HOSPITAL
    Please answer the following questions
    about your stay at the hospital named on
    the cover letter. Do not include any other
    hospital stays in your answers.
  21. 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 stay?
    0 0 Worst hospital possible
    1 1
    2 2
    3 3
    4 4
    5 5
    6 6
    7 7
    8 8
    9 9
    1010 Best hospital possible
    4 January 2018
  22. Would you recommend this hospital
    to your friends and family?
    1 Definitely no
    2 Probably no
    3 Probably yes
    4 Definitely yes
    UNDERSTANDING YOUR CARE
    WHEN YOU LEFT THE HOSPITAL
  23. During this hospital stay, staff took
    my preferences and those of my
    family or caregiver into account in
    deciding what my health care needs
    would be when I left.
    1 Strongly disagree
    2 Disagree
    3 Agree
    4 Strongly agree
  24. When I left the hospital, I had a good
    understanding of the things I was
    responsible for in managing my
    health.
    1 Strongly disagree
    2 Disagree
    3 Agree
    4 Strongly agree
  25. When I left the hospital, I clearly
    understood the purpose for taking
    each of my medications.
    1 Strongly disagree
    2 Disagree
    3 Agree
    4 Strongly agree
    5 I was not given any medication when
    I left the hospital
    ABOUT YOU
    There are only a few remaining items left.
  26. During this hospital stay, were you
    admitted to this hospital through the
    Emergency Room?
    1 Yes
    2 No
  27. In general, how would you rate your
    overall health?
    1 Excellent
    2 Very good
    3 Good
    4 Fair
    5 Poor
  28. In general, how would you rate your
    overall mental or emotional health?
    1 Excellent
    2 Very good
    3 Good
    4 Fair
    5 Poor
  29. 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
    January 2018 5
  30. Are you of Spanish, Hispanic or
    Latino origin or descent?
    1 No, not Spanish/Hispanic/Latino
    2 Yes, Puerto Rican
    3 Yes, Mexican, Mexican American,
    Chicano
    4 Yes, Cuban
    5 Yes, other Spanish/Hispanic/Latino
  31. What is your race? Please choose
    one or more.
    1 White
    2 Black or African American
    3 Asian
    4 Native Hawaiian or other Pacific
    Islander
    5 American Indian or Alaska Native
  32. What language do you mainly speak
    at home?
    1 English
    2 Spanish
    3 Chinese
    4 Russian
    5 Vietnamese
    6 Portuguese
    9 Some other language (please print):

THANK YOU
Please return the completed survey in the postage-paid envelope.
[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]
[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING
HOSPITAL]
Questions 1-22 and 26-32 are part of the HCAHPS Survey and are works of the U.S.
Government. These HCAHPS questions are in the public domain and therefore are NOT
subject to U.S. copyright laws. The three Care Transitions Measure® questions (Questions
23-25) are copyright of Eric A. Coleman, MD, MPH, all rights reserved.
6 January 2018
January 2018 7
HCAHPS Survey
SURVEY INSTRUCTIONS
 You should only fill out this survey if you were the patient during the hospital stay named in the
cover letter. Do not fill out this survey if you were not the patient.
 Answer all the questions 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:
0 Yes
0 No  If No, Go to Question 1
You may notice a number on the survey. This number is used to let us know if you
returned your survey so we don’t have to send you reminders.
Please note: Questions 1-25 in this survey are part of a national initiative to measure the quality of care
in hospitals. OMB #0938-0981
Please answer the questions in this survey
about your stay at the hospital named on
the cover letter. Do not include any other
hospital stays in your answers.
YOUR CARE FROM NURSES

  1. During this hospital stay, how often
    did nurses treat you with courtesy
    and respect?
    10 Never
    20 Sometimes
    30 Usually
    40 Always
  2. During this hospital stay, how often
    did nurses listen carefully to you?
    10 Never
    20 Sometimes
    30 Usually
    40 Always
  3. During this hospital stay, how often
    did nurses explain things in a way
    you could understand?
    10 Never
    20 Sometimes
    30 Usually
    40 Always
  4. During this hospital stay, after you
    pressed the call button, how often did
    you get help as soon as you wanted
    it?
    10 Never
    20 Sometimes
    30 Usually
    40 Always
    90 I never pressed the call button
    8 January 2018
    YOUR CARE FROM DOCTORS
  5. During this hospital stay, how often
    did doctors treat you with courtesy
    and respect?
    10 Never
    20 Sometimes
    30 Usually
    40 Always
  6. During this hospital stay, how often
    did doctors listen carefully to you?
    10 Never
    20 Sometimes
    30 Usually
    40 Always
  7. During this hospital stay, how often
    did doctors explain things in a way
    you could understand?
    10 Never
    20 Sometimes
    30 Usually
    40 Always
    THE HOSPITAL ENVIRONMENT
  8. During this hospital stay, how often
    were your room and bathroom kept
    clean?
    10 Never
    20 Sometimes
    30 Usually
    40 Always
  9. During this hospital stay, how often
    was the area around your room quiet
    at night?
    10 Never
    20 Sometimes
    30 Usually
    40 Always
    YOUR EXPERIENCES IN THIS HOSPITAL
  10. During this hospital stay, did you
    need help from nurses or other
    hospital staff in getting to the
    bathroom or in using a bedpan?
    10 Yes
    20 No  If No, Go to Question 12
  11. How often did you get help in getting
    to the bathroom or in using a bedpan
    as soon as you wanted?
    10 Never
    20 Sometimes
    30 Usually
    40 Always
  12. During this hospital stay, did you
    have any pain?
    10 Yes
    20 No  If No, Go to Question 15
  13. During this hospital stay, how often
    did hospital staff talk with you about
    how much pain you had?
    10 Never
    20 Sometimes
    30 Usually
    40 Always
    January 2018 9
  14. During this hospital stay, how often
    did hospital staff talk with you about
    how to treat your pain?
    10 Never
    20 Sometimes
    30 Usually
    40 Always
  15. During this hospital stay, were you
    given any medicine that you had not
    taken before?
    10 Yes
    20 No  If No, Go to Question 18
  16. Before giving you any new medicine,
    how often did hospital staff tell you
    what the medicine was for?
    10 Never
    20 Sometimes
    30 Usually
    40 Always
  17. Before giving you any new medicine,
    how often did hospital staff describe
    possible side effects in a way you
    could understand?
    10 Never
    20 Sometimes
    30 Usually
    40 Always
    WHEN YOU LEFT THE HOSPITAL
  18. After you left the hospital, did you go
    directly to your own home, to
    someone else’s home, or to another
    health facility?
    10 Own home
    20 Someone else’s home
    30 Another health
    facility  If Another, Go to
    Question 21
  19. During this hospital stay, did doctors,
    nurses or other hospital staff talk with
    you about whether you would have
    the help you needed when you left the
    hospital?
    10 Yes
    20 No
  20. During this hospital stay, did you get
    information in writing about what
    symptoms or health problems to look
    out for after you left the hospital?
    10 Yes
    20 No
    OVERALL RATING OF HOSPITAL
    Please answer the following questions
    about your stay at the hospital named on
    the cover letter. Do not include any other
    hospital stays in your answers.
  21. 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 stay?
    00 0 Worst hospital possible
    10 1
    20 2
    30 3
    40 4
    50 5
    60 6
    70 7
    80 8
    90 9
    100 10 Best hospital possible
    10 January 2018
  22. Would you recommend this hospital
    to your friends and family?
    10 Definitely no
    20 Probably no
    30 Probably yes
    40 Definitely yes
    UNDERSTANDING YOUR CARE
    WHEN YOU LEFT THE HOSPITAL
  23. During this hospital stay, staff took
    my preferences and those of my
    family or caregiver into account in
    deciding what my health care needs
    would be when I left.
    10 Strongly disagree
    20 Disagree
    30 Agree
    40 Strongly agree
  24. When I left the hospital, I had a good
    understanding of the things I was
    responsible for in managing my
    health.
    10 Strongly disagree
    20 Disagree
    30 Agree
    40 Strongly agree
  25. When I left the hospital, I clearly
    understood the purpose for taking
    each of my medications.
    10 Strongly disagree
    20 Disagree
    30 Agree
    40 Strongly agree
    50 I was not given any medication when
    I left the hospital
    ABOUT YOU
    There are only a few remaining items left.
  26. During this hospital stay, were you
    admitted to this hospital through the
    Emergency Room?
    10 Yes
    20 No
  27. In general, how would you rate your
    overall health?
    10 Excellent
    20 Very good
    30 Good
    40 Fair
    50 Poor
  28. In general, how would you rate your
    overall mental or emotional health?
    10 Excellent
    20 Very good
    30 Good
    40 Fair
    50 Poor
  29. What is the highest grade or level of
    school that you have completed?
    10 8th grade or less
    20 Some high school, but did not
    graduate
    30 High school graduate or GED
    40 Some college or 2-year degree
    50 4-year college graduate
    60 More than 4-year college degree
    January 2018 11
  30. Are you of Spanish, Hispanic or
    Latino origin or descent?
    10 No, not Spanish/Hispanic/Latino
    20 Yes, Puerto Rican
    30 Yes, Mexican, Mexican American,
    Chicano
    40 Yes, Cuban
    50 Yes, other Spanish/Hispanic/Latino
  31. What is your race? Please choose
    one or more.
    10 White
    20 Black or African American
    30 Asian
    40 Native Hawaiian or other Pacific
    Islander
    50 American Indian or Alaska Native
  32. What language do you mainly speak
    at home?
    10 English
    20 Spanish
    30 Chinese
    40 Russian
    50 Vietnamese
    60 Portuguese
    90 Some other language (please print):

THANK YOU
Please return the completed survey in the postage-paid envelope.
[NAME OF SURVEY VENDOR OR SELF-ADMINISTERING HOSPITAL]
[RETURN ADDRESS OF SURVEY VENDOR OR SELF-ADMINISTERING
HOSPITAL]
Questions 1-22 and 26-32 are part of the HCAHPS Survey and are works of the U.S.
Government. These HCAHPS questions are in the public domain and therefore are NOT
subject to U.S. copyright laws. The three Care Transitions Measure® questions (Questions
23-25) are copyright of Eric A. Coleman, MD, MPH, all rights reserved.
12 January 2018
January 2018 13
Sample Initial Cover Letter for the HCAHPS Survey
[HOSPITAL LETTERHEAD]
[SAMPLED PATIENT NAME]
[ADDRESS]
[CITY, STATE ZIP]
Dear [SAMPLED PATIENT NAME]:
Our records show that you were recently a patient at [NAME OF HOSPITAL] and discharged on
[DATE OF DISCHARGE (mm/dd/yyyy)]. Because you had a recent hospital stay, we are asking
for your help. This survey is part of an ongoing national effort to understand how patients view
their hospital experience. Hospital results will be publicly reported and made available on the
Internet at www.medicare.gov/hospitalcompare. These results will help consumers make
important choices about their hospital care, and will help hospitals improve the care they provide.
Questions 1-25 in the enclosed survey are part of a national initiative sponsored by the United
States Department of Health and Human Services to measure the quality of care in hospitals.
Your participation is voluntary and will not affect your health benefits.
We hope that you will take the time to complete the survey. Your participation is greatly
appreciated. After you have completed the survey, please return it in the pre-paid envelope. Your
answers may be shared with the hospital for purposes of quality improvement. [OPTIONAL: You
may notice a number on the survey. This number is used to let us know if you returned your
survey so we don’t have to send you reminders.]
If you have any questions about the enclosed survey, please call the toll-free number 1-800-xxxxxxx. Thank you for helping to improve health care for all consumers.
Sincerely,
[HOSPITAL ADMINISTRATOR]
[HOSPITAL NAME]
Note: The OMB Paperwork Reduction Act language must be included in the mailing. This
language can be either on the front or back of the cover letter or questionnaire, but cannot be a
separate mailing. The exact OMB Paperwork Reduction Act language is included in this
appendix. Please refer to the Mail Only, and Mixed Mode sections, for specific letter guidelines.
14 January 2018
January 2018 15
Sample Follow-up Cover Letter for the HCAHPS Survey
[HOSPITAL LETTERHEAD]
[SAMPLED PATIENT NAME]
[ADDRESS]
[CITY, STATE ZIP]
Dear [SAMPLED PATIENT NAME]:
Our records show that you were recently a patient at [NAME OF HOSPITAL] and discharged on
[DATE OF DISCHARGE (mm/dd/yyyy)]. Approximately three weeks ago we sent you a survey
regarding your hospitalization. If you have already returned the survey to us, please accept our
thanks and disregard this letter. However, if you have not yet completed the survey, please take a
few minutes and complete it now.
Because you had a recent hospital stay, we are asking for your help. This survey is part of an
ongoing national effort to understand how patients view their hospital experience. Hospital
results will be publicly reported and made available on the Internet at
www.medicare.gov/hospitalcompare. These results will help consumers make important choices
about their hospital care, and will help hospitals improve the care they provide.
Questions 1-25 in the enclosed survey are part of a national initiative sponsored by the United
States Department of Health and Human Services to measure the quality of care in hospitals.
Your participation is voluntary and will not affect your health benefits. Please take a few minutes
and complete the enclosed survey. After you have completed the survey, please return it in the
pre-paid envelope. Your answers may be shared with the hospital for purposes of quality
improvement. [OPTIONAL: You may notice a number on the survey. This number is used to let
us know if you returned your survey so we don’t have to send you reminders.]
If you have any questions about the enclosed survey, please call the toll-free number 1-800-xxxxxxx. Thank you again for helping to improve health care for all consumers.
Sincerely,
[HOSPITAL ADMINISTRATOR]
[HOSPITAL NAME]
Note: The OMB Paperwork Reduction Act language must be included in the mailing. This
language can be either on the front or back of the cover letter or questionnaire, but cannot be a
separate mailing. The exact OMB Paperwork Reduction Act language is included in this
appendix. Please refer to the Mail Only, and Mixed Mode sections, for specific letter guidelines.
16 January 2018
January 2018 17
OMB Paperwork Reduction Act Language
The OMB Paperwork Reduction Act language must be included in the survey mailing. This
language can be either on the front or back of the cover letter or questionnaire, but cannot be a
separate mailing. The following is the language that must be used:
English Version
“According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control
number for this information collection is 0938-0981. The time required to complete this
information collected is estimated to average 8 minutes for questions 1-25 on the survey,
including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collection. If you have any comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: Centers
for Medicare & Medicaid Services, 7500 Security Boulevard, C1-25-05, Baltimore, MD 21244-
1850.”
18 January 20