March 2017 1
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
1. During this hospital stay, how often
did nurses treat you with courtesy
2. During this hospital stay, how often
did nurses listen carefully to you?
3. During this hospital stay, how often
did nurses explain things in a way
you could understand?
4. During this hospital stay, after you
pressed the call button, how often did
you get help as soon as you wanted