CAHPS Survey

Form approved: OMB No. 3206-0274.
CAHPS 5.1H MY2024
CLV1

Survey Instructions
Answer each question by marking 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:
1 Yes → If Yes, Go to Question 1
2 No
Personally identifiable information will not be made public and will only be released in accordance with
federal laws and regulations.
You may choose to answer this survey or not. If you choose not to, this will not affect the benefits you
get. You may notice a number on the cover of this survey. This number is ONLY used to let us know if you
returned your survey so we don’t have to send you reminders.
If you want to know more about this study, please call 1-800-874-5561.

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1. Our records show that you are now in
Calvo’s SelectCare. Is that right?
1 Yes → If Yes, Go to Question 3
2 No

5. In the last 12 months, did you make any
in person, phone, or video appointments for
a check-up or routine care?
1 Yes
2 No → If No, Go to Question 7

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2. What is the name of your health plan?
(Please print)

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Your Health Care in the Last 12 months
These questions ask about your own health care
from a clinic, emergency room, or doctor’s office.
This includes care you got in person, by phone, or
by video. Do not include care you got when you
stayed overnight in a hospital. Do not include the
times you went for dental care visits.

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7. In the last 12 months, not counting the times you
went to an emergency room, how many times
did you get health care for yourself in person,
by phone, or by video?
0 None → If None, Go to Question 10
1 1 time
2 2
3 3
4 4
5 5 to 9
6 10 or more times

3. In the last 12 months, did you have an illness,
injury, or condition that needed care right away?
1 Yes
2 No → If No, Go to Question 5

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4. In the last 12 months, when you needed care right
away, how often did you get care as soon as you
needed?
1 Never
2 Sometimes
3 Usually
4 Always

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6. In the last 12 months, how often did you get an
appointment for a check-up or routine care as
soon as you needed?
1 Never
2 Sometimes
3 Usually
4 Always

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8. Using any number from 0 to 10, where 0 is the
worst health care possible and 10 is the best
health care possible, what number would you use
to rate all your health care in the last 12 months?
0 1 2 3 4 5 6 7 8 9 10

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Worst health care
Best health care
possible possible

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9. In the last 12 months, how often was it easy to get
the care, tests, or treatment you needed?
1 Never
2 Sometimes
3 Usually
4 Always

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15. In the last 12 months, how often did your personal
doctor spend enough time with you?
1 Never
2 Sometimes
3 Usually
4 Always

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16. In the last 12 months, did you get care from a
doctor or other health provider besides your
personal doctor?
1 Yes
2 No → If No, Go to Question 18

Your Personal Doctor

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10. A personal doctor is the one you would talk to
if you need a check-up, want advice about a
health problem, or get sick or hurt. Do you have
a personal doctor?
1 Yes
2 No → If No, Go to Question 19

17. In the last 12 months, how often did your personal
doctor seem informed and up-to-date about the
care you got from these doctors or other health
providers?
1 Never
2 Sometimes
3 Usually
4 Always

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11. In the last 12 months, how many times did you
have an in person, phone, or video visit with your
personal doctor about your health?
0 None → If None, Go to Question 18
1 1 time
2 2
3 3
4 4
5 5 to 9
6 10 or more times

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18. Using any number from 0 to 10, where 0 is the
worst personal doctor possible and 10 is the best
personal doctor possible, what number would you
use to rate your personal doctor?
0 1 2 3 4 5 6 7 8 9 10

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12. In the last 12 months, how often did your personal
doctor explain things in a way that was easy to
understand?
1 Never
2 Sometimes
3 Usually
4 Always

Worst personal
doctor possible

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Getting Health Care From Specialists

13. In the last 12 months, how often did your personal
doctor listen carefully to you?
1 Never
2 Sometimes
3 Usually
4 Always

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14. In the last 12 months, how often did your personal
doctor show respect for what you had to say?
1 Never
2 Sometimes
3 Usually
4 Always

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Best personal
doctor possible

When you answer the next questions, include
the care you got in person, by phone, or by video.
Do not include dental visits or care you got when
you stayed overnight in a hospital.
19. Specialists are doctors like surgeons, heart doctors,
allergy doctors, skin doctors, and other doctors
who specialize in one area of health care. In the
last 12 months, did you make any appointments
with a specialist?
1 Yes
2 No → If No, Go to Question 23

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20. In the last 12 months, how often did you get an
appointment with a specialist as soon as you needed?
1 Never
2 Sometimes
3 Usually
4 Always

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21. How many specialists have you talked to in the
last 12 months?
0 None → If None, Go to Question 23
1 1 specialist
2 2
3 3
4 4
5 5 or more specialists

27. In the last 12 months, how often were the forms
from your health plan easy to fill out?
1 Never
2 Sometimes
3 Usually
4 Always

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22. We want to know your rating of the specialist you
talked to most often in the last 12 months. Using any
number from 0 to 10, where 0 is the worst specialist
possible and 10 is the best specialist possible, what
number would you use to rate that specialist?
0 1 2 3 4 5 6 7 8 9 10

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Worst specialist
Best specialist
possible possible

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29. In the last 12 months, how often did your health
plan handle your claims quickly?
1 Never
2 Sometimes
3 Usually
4 Always
5 Don’t know

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Your Health Plan
The next questions ask about your experience
with your health plan.
23. In the last 12 months, did you get information or
help from your health plan’s customer service?
1 Yes
2 No → If No, Go to Question 26

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24. In the last 12 months, how often did your health
plan’s customer service give you the information or
help you needed?
1 Never
2 Sometimes
3 Usually
4 Always

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30. In the last 12 months, how often did your health
plan handle your claims correctly?
1 Never
2 Sometimes
3 Usually
4 Always
5 Don’t know

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31. Using any number from 0 to 10, where 0 is the
worst health plan possible and 10 is the best health
plan possible, what number would you use to rate
your health plan?
0 1 2 3 4 5 6 7 8 9 10

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25. In the last 12 months, how often did your health
plan’s customer service staff treat you with
courtesy and respect?
1 Never
2 Sometimes
3 Usually
4 Always

Worst health plan
Best health plan
possible possible

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About You

26. In the last 12 months, did your health plan give you
any forms to fill out?
1 Yes
2 No → If No, Go to Question 28

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28. Claims are sent to a health plan for payment.
You may send in the claims yourself, or doctors,
hospitals, or others may do this for you. In the last
12 months, did you or anyone else send in any
claims for your care to your health plan?
1 Yes
2 No → If No, Go to Question 31
3 Don’t know → If Don’t know,
Go to Question 31

32. In general, how would you rate your overall health?
1 Excellent
2 Very good
3 Good
4 Fair
5 Poor

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33. In general, how would you rate your overall mental
or emotional health?
1 Excellent
2 Very good
3 Good
4 Fair
5 Poor

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34. Do you now smoke cigarettes or use tobacco every
day, some days, or not at all?
1 Every day
2 Some days
3 Not at all → If Not at all, Go to Question 38
4 Don’t know → If Don’t know,
Go to Question 38

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35. In the last 12 months, how often were you advised
to quit smoking or using tobacco by a doctor or
other health provider in your plan?
1 Never
2 Sometimes
3 Usually
4 Always

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36. In the last 12 months, how often was medication
recommended or discussed by a doctor or health
provider to assist you with quitting smoking or
using tobacco? Examples of medication are:
nicotine gum, patch, nasal spray, inhaler, or
prescription medication.
1 Never
2 Sometimes
3 Usually
4 Always

39. Are you male or female?
1 Male
2 Female

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40. 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

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41. Are you of Hispanic or Latino origin or descent?
1 Yes, Hispanic or Latino
2 No, not Hispanic or Latino

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37. In the last 12 months, how often did your doctor
or health provider discuss or provide methods and
strategies other than medication to assist you with
quitting smoking or using tobacco? Examples of
methods and strategies are: telephone helpline,
individual or group counseling, or cessation program.
1 Never
2 Sometimes
3 Usually
4 Always

AC_4E_GEN1

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42. What is your race? Mark one or more.
a White
b Black or African-American
c Asian
d Native Hawaiian or other Pacific Islander
e American Indian or Alaska Native
f Other

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38. 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

Thank You
Please return the completed survey in the
postage-paid envelope to:
Center for the Study of Services
PO Box 3416
Hopkins, MN 55343
Please do not include any other correspondence.
The public reporting burden to complete this information collection is estimated at
20 minutes per response, including time for reviewing instructions, searching data
sources, gathering and maintaining the data needed, and completing and reviewing
the collected 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 the Office of Personnel Management at FormsPRA@OPM.gov.
Current information regarding this collection of information, including all
background materials, can be found at https:/www.reginfo.gov/public/do/PRAMain
by using the search function to enter either the title Consumer Assessment of
Healthcare Providers and Systems (CAHPS®) Surveyor 3206-0274.

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