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 1-29 in this survey are part of a national initiative to measure the quality
of care in hospitals. OMB #0938-0981 (Expires September 30, 2024)

Please answer the questions in this survey 3. During this hospital stay, how often
about your stay at the hospital named on did nurses explain things in a way
the cover letter. Do not include any other you could understand?
hospital stays in your answers. 1 Never
YOUR CARE FROM NURSES
2 Sometimes
3 Usually
1. During this hospital stay, how often 4 Always
did nurses treat you with courtesy
and respect?
4. During this hospital stay, after you
1 Never pressed the call button, how often did
2 Sometimes you get help as soon as you wanted
3 Usually
it?
4 Always 1 Never
2 Sometimes
2. During this hospital stay, how often 3 Usually
did nurses listen carefully to you? 4 Always
1 Never 9 I never pressed the call button
2 Sometimes

3 Usually

4 Always

March 2023 1
 YOUR CARE FROM DOCTORS YOUR EXPERIENCES IN THIS HOSPITAL
5. During this hospital stay, how often 10. During this hospital stay, did you
did doctors treat you with courtesy need help from nurses or other
and respect? hospital staff in getting to the
bathroom or in using a bedpan?
1 Never
2 Sometimes 1 Yes
3 Usually 2 No  If No, Go to Question 12
4 Always
11. How often did you get help in getting
to the bathroom or in using a bedpan
6. During this hospital stay, how often
as soon as you wanted?
did doctors listen carefully to you?
1 Never
1 Never
2 Sometimes
2 Sometimes
3 Usually
3 Usually
4 Always
4 Always

12. During this hospital stay, were you

7. During this hospital stay, how often
given any medicine that you had not
did doctors explain things in a way
taken before?
you could understand?
1 Never
1  Yes
2 No  If No, Go to Question 15
2 Sometimes

3 Usually
13. Before giving you any new medicine,
4 Always how often did hospital staff tell you
what the medicine was for?
THE HOSPITAL ENVIRONMENT 1 Never
8. During this hospital stay, how often 2 Sometimes
were your room and bathroom kept 3 Usually
clean?
4 Always
1 Never
2 Sometimes 14. Before giving you any new medicine,
3 Usually how often did hospital staff describe
possible side effects in a way you
4 Always
could understand?
9. During this hospital stay, how often 1 Never
was the area around your room quiet 2 Sometimes
at night? 3 Usually
1 Never 4 Always
2 Sometimes
3 Usually

4 Always

2 March 2023
 WHEN YOU LEFT THE HOSPITAL OVERALL RATING OF HOSPITAL
15. After you left the hospital, did you go Please answer the following questions
directly to your own home, to about your stay at the hospital named on
someone else’s home, or to another the cover letter. Do not include any other
health facility? hospital stays in your answers.
1 Own home 18. Using any number from 0 to 10, where
2 Someone else’s home 0 is the worst hospital possible and
10 is the best hospital possible, what
3 Another health
number would you use to rate this
facility  If Another, Go to hospital during your stay?
Question 18
00 Worst hospital possible
1 1
16. During this hospital stay, did doctors,
nurses or other hospital staff talk with 2 2
you about whether you would have 3 3
the help you needed when you left the
4 4
hospital?
5 5
1 Yes 6 6
2 No 7 7

17. During this hospital stay, did you get 8 8

information in writing about what 9 9

symptoms or health problems to look 1010
out for after you left the hospital? Best hospital possible

1 Yes 19. Would you recommend this hospital

2 No 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
20. 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

March 2023 3
21. When I left the hospital, I had a good 25. In general, how would you rate your
understanding of the things I was overall mental or emotional health?
responsible for in managing my
health.
1 Excellent
2 Very good
1 Strongly disagree
3 Good
2 Disagree
4 Fair
3 Agree
5 Poor
4 Strongly agree

26. What is the highest grade or level of

22. When I left the hospital, I clearly
school that you have completed?
understood the purpose for taking
each of my medications. 1  8th grade or less
1 Strongly disagree 2  Some high school, but did not
2 Disagree graduate
3 Agree
3 High school graduate or GED
4 Some college or 2-year degree
4 Strongly agree
5 4-year college graduate
5 I was not given any medication when
6 More than 4-year college degree
I left the hospital

ABOUT YOU 27. Are you of Spanish, Hispanic or

Latino origin or descent?
There are only a few remaining items left.
23. During this hospital stay, were you
1 No, not Spanish/Hispanic/Latino
admitted to this hospital through the
2 Yes, Puerto Rican
Emergency Room? 3 Yes, Mexican, Mexican American,

Chicano
1 Yes
2 No
4 Yes, Cuban
5 Yes, other Spanish/Hispanic/Latino

24. In general, how would you rate your

overall health? 28. What is your race? Please choose one
or more.
1 Excellent
2 Very good
1 White
3 Good
2 Black or African American
3 Asian
4 Fair
4 Native Hawaiian or other Pacific
5 Poor
Islander
5  American Indian or Alaska Native

4 March 2023
29. What language do you mainly speak
at home?
1 English
2 Spanish
3 Chinese
4 Russian
5 Vietnamese
6 Portuguese
7 German
8 Tagalog
9 Arabic
20 Some other language (please
print): _____________________

NOTE: IF HOSPITAL-SPECIFIC
SUPPLEMENTAL QUESTION(S) ARE
ADDED, THE MANDATORY TRANSITION
STATEMENT MUST BE PLACED
IMMEDIATELY BEFORE THE
SUPPLEMENTAL QUESTION(S).

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 1-19 and 23-29 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 20-22) are copyright
of Eric A. Coleman, MD, MPH, all rights reserved.

March 2023 5
6 March 2023
 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 1-29 in this survey are part of a national initiative to measure the quality of care
in hospitals. OMB #0938-0981 (Expires September 30, 2024)

Please answer the questions in this survey 3. During this hospital stay, how often
about your stay at the hospital named on did nurses explain things in a way
the cover letter. Do not include any other you could understand?
hospital stays in your answers. 10 Never
20
YOUR CARE FROM NURSES Sometimes
30 Usually
1. During this hospital stay, how often
did nurses treat you with courtesy 40 Always
and respect?
4. During this hospital stay, after you
10 Never pressed the call button, how often did
20 Sometimes you get help as soon as you wanted
30 Usually it?
40 Always 10 Never
20 Sometimes
2. During this hospital stay, how often 30 Usually
did nurses listen carefully to you? 40 Always
10 Never 90 I never pressed the call button
20 Sometimes
30 Usually
40 Always

March 2023 7
 YOUR CARE FROM DOCTORS 9. During this hospital stay, how often
was the area around your room quiet
5. During this hospital stay, how often at night?
did doctors treat you with courtesy
and respect? 10 Never
10 Never
20 Sometimes
30 Usually
20 Sometimes
40 Always
30 Usually
40 Always YOUR EXPERIENCES IN THIS HOSPITAL

6. During this hospital stay, how often 10. During this hospital stay, did you
did doctors listen carefully to you? need help from nurses or other
hospital staff in getting to the
10 Never bathroom or in using a bedpan?
20 Sometimes 0
1 Yes
30 Usually 0
2 No  If No, Go to Question 12
40 Always
11. How often did you get help in getting
7. During this hospital stay, how often to the bathroom or in using a bedpan
did doctors explain things in a way as soon as you wanted?
you could understand?
10 Never
10 Never 20 Sometimes
20 Sometimes 30 Usually
30 Usually 40 Always
40 Always
12. During this hospital stay, were you
THE HOSPITAL ENVIRONMENT given any medicine that you had not
8. During this hospital stay, how often taken before?
were your room and bathroom kept 1 0 Yes
clean?
2 0 No  If No, Go to Question 15
10 Never
20 Sometimes 13. Before giving you any new medicine,
30
how often did hospital staff tell you
Usually what the medicine was for?
40 Always 10 Never
20 Sometimes
30 Usually
40 Always

8 March 2023
14. Before giving you any new medicine, OVERALL RATING OF HOSPITAL
how often did hospital staff describe
possible side effects in a way you Please answer the following questions
could understand? about your stay at the hospital named on
the cover letter. Do not include any other
10 Never hospital stays in your answers.
20 Sometimes 18. Using any number from 0 to 10, where
30 Usually 0 is the worst hospital possible and
40 Always 10 is the best hospital possible, what
number would you use to rate this
hospital during your stay?
WHEN YOU LEFT THE HOSPITAL
00 0 Worst hospital possible
15. After you left the hospital, did you go
directly to your own home, to
10 1
20 2
someone else’s home, or to another
health facility? 30 3
40
10 Own home 4
20 50 5
Someone else’s home
30 60 6
Another health
facility  If Another, Go to 70 7
Question 18 80 8
90 9
16. During this hospital stay, did doctors,
nurses or other hospital staff talk with 100 10 Best hospital possible
you about whether you would have
the help you needed when you left the 19. Would you recommend this hospital
hospital? to your friends and family?
10 Yes 10 Definitely no
20 No 20 Probably no
30 Probably yes
17. During this hospital stay, did you get 40
information in writing about what Definitely yes
symptoms or health problems to look
out for after you left the hospital? UNDERSTANDING YOUR CARE
WHEN YOU LEFT THE HOSPITAL
10 Yes
20 20. During this hospital stay, staff took
No
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
March 2023 9
21. When I left the hospital, I had a good 25. In general, how would you rate your
understanding of the things I was overall mental or emotional health?
responsible for in managing my
health.
10 Excellent
20 Very good
10 Strongly disagree 30 Good
20 Disagree 40 Fair
30 Agree 50 Poor
40 Strongly agree
26. What is the highest grade or level of
22. When I left the hospital, I clearly school that you have completed?
understood the purpose for taking
each of my medications. 10 8th grade or less
20 Some high school, but did not
10 Strongly disagree
graduate
20 Disagree
30
30 High school graduate or GED
Agree 40 Some college or 2-year degree
40 Strongly agree 50 4-year college graduate
50 I was not given any medication when 60 More than 4-year college degree
I left the hospital
27. Are you of Spanish, Hispanic or
ABOUT YOU Latino origin or descent?
There are only a few remaining items left. 10 No, not Spanish/Hispanic/Latino
23. During this hospital stay, were you 20 Yes, Puerto Rican
admitted to this hospital through the
30 Yes, Mexican, Mexican American,
Emergency Room?
Chicano
0
1 Yes 40 Yes, Cuban
0
2 No 50 Yes, other Spanish/Hispanic/Latino
24. In general, how would you rate your 28. What is your race? Please choose one
overall health? or more.
10 Excellent 10 White
20 Very good 20 Black or African American
30 Good 30 Asian
40 Fair 40 Native Hawaiian or other Pacific
50 Poor Islander
5 0 American Indian or Alaska Native

10 March 2023
29. What language do you mainly speak
at home?
10 English
20 Spanish

30 Chinese

40 Russian

50 Vietnamese

60 Portuguese

70 German

80 Tagalog

90 Arabic

200 Some other language (please print):

_____________________

NOTE: IF HOSPITAL-SPECIFIC
SUPPLEMENTAL QUESTION(S) ARE
ADDED, THE MANDATORY TRANSITION
STATEMENT MUST BE PLACED
IMMEDIATELY BEFORE THE
SUPPLEMENTAL QUESTION(S).

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 1-19 and 23-29 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 20-22) are copyright
of Eric A. Coleman, MD, MPH, all rights reserved.

March 2023 11
12 March 2023
 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.

The enclosed survey is part of an effort to understand how patients view their hospital care.
Questions 1-29 in the survey are sponsored by the United States Department of Health and Human
Services and should take about 7 minutes to complete.

Your participation is voluntary and your answers will be kept private. Your responses will help
improve the quality of hospital care and help other people make more informed choices about their
care. You can see current survey results and find hospital ratings on Care Compare on Medicare.gov
(www.medicare.gov/care-compare).

After you have completed the survey, please return it in the enclosed pre-paid envelope. If you have
any questions about the survey, please call this toll-free number: 1-xxx-xxx-xxxx.

We greatly appreciate your help in improving hospital care.

Sincerely,

[HOSPITAL ADMINISTRATOR]
[HOSPITAL NAME]

March 2023 13
14 March 2023
 Sample Follow-up Cover Letter for the HCAHPS Survey

[HOSPITAL LETTERHEAD]

[SAMPLED PATIENT NAME]

[ADDRESS]
[CITY, STATE ZIP]

Dear [SAMPLED PATIENT NAME]:

A few weeks ago, we sent you a survey asking for your feedback on your recent experience at
[NAME OF HOSPITAL] discharged on [DATE OF DISCHARGE (mm/dd/yyyy)]. 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.

The enclosed survey is part of an effort to understand how patients view their hospital care.
Questions 1-29 in the survey are sponsored by the United States Department of Health and Human
Services and should take about 7 minutes to complete.

Your participation is voluntary and your answers will be kept private. Your responses will help
improve the quality of hospital care and help other people make more informed choices about their
care. You can see current survey results and find hospital ratings on Care Compare on Medicare.gov
(www.medicare.gov/care-compare).

After you have completed the survey, please return it in the enclosed pre-paid envelope. If you have
any questions about the survey, please call this toll-free number: 1-xxx-xxx-xxxx.

We greatly appreciate your help in improving hospital care.

Sincerely,

[HOSPITAL ADMINISTRATOR]
[HOSPITAL NAME]

March 2023 15
16 March 2023
 Survey and Cover Letter Required Language
For the full set of requirements for the HCAHPS Survey questionnaire and cover letters, please see
the HCAHPS Quality Assurance Guidelines, Mail Only and Mixed Mode Survey Administration
chapters.

Verbatim Language on the Cover Letters

The following sentences must appear verbatim on each cover letter:
1. Questions 1-29 in the survey are sponsored by the United States Department of Health
and Human Services and should take about 7 minutes to complete.

2. Your participation is voluntary and your answers will be kept private.

3. Your responses will help improve the quality of hospital care and help other people make
more informed choices about their care. You can see current survey results and find
hospital ratings on Care Compare on Medicare.gov (www.medicare.gov/care-compare).

OMB Paperwork Reduction Act Language

The OMB Paperwork Reduction Act language must appear verbatim either on the front or back
of the questionnaire (preferred) or cover letter, but cannot be a separate mailing. The following
is the language that must be used:
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 (Expires September 30, 2024).
The time required to complete this information collected is estimated to average 7 minutes
for questions 1-29 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.

Mandatory Transition Statement if Supplemental Items Are Added

The mandatory transition statement must be placed in the questionnaire immediately before the
supplemental question(s) to indicate a transition from the HCAHPS questions (Questions 1-29)
to the hospital-specific supplemental question or questions.

The following statement must be placed immediately before the addition of a single supplemental
question:
Questions 1-29 in this survey are from the U.S. Department of Health and Human
Services (HHS) for use in quality measurement. The following question is from [NAME
OF HOSPITAL] to gather additional feedback about your hospital stay and will not be
shared with HHS.

The following statement must be placed immediately before the addition of more than one
supplemental question:
Questions 1-29 in this survey are from the U.S. Department of Health and Human
Services (HHS) for use in quality measurement. The following questions are from
[NAME OF HOSPITAL] to gather additional feedback about your hospital stay and
will not be shared with HHS.
March 2023 17
Unique Identifier Language
The following language indicates the purpose of the unique identifier. This language must be
printed either immediately after the survey instructions on the questionnaire (preferred) or on
the cover letter, and may appear on both:
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.

Copyright Statement
The following copyright statement must be included on the questionnaire, preferably on the last
page:
Questions 1-19 and 23-29 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
20-22) are copyright of Eric A. Coleman, MD, MPH, all rights reserved.

Reply-by Date (Optional)

It is optional to include a reply-by date in the follow-up cover letter. However, if a reply-by date
is included, the placement requirements below must be followed.

The following two placement options are available for adding a reply-by date to the follow-up
cover letter:
1. Placed above the salutation, such as:
Please reply by: [DATE (mm/dd/yyyy)].

2. In the fourth paragraph replace the sentence, “After you have completed the survey,
please return it in the enclosed pre-paid envelope” with reply-by text such as:
Please fill out the enclosed survey and mail it by [DATE (mm/dd/yyyy)] in the pre-paid
envelope.

18 March 2023