Using any number from 0 to 10, where 0 is the worst kidney doctors possible and 10 is the best kidney doctors possible, what number would you use to rate the kidney doctors you have now? 0 0 Worst kidney doctors possible 1 1 2 2 3 3 4 4 5 5 6 6 7 7 8 8 9 9 10 10 Best kidney doctors possible Do your kidney doctors seem informed and up-to-date about the health care you receive from other doctors? 1 Yes 2 No For the next questions, dialysis center staff does not include doctors. Dialysis center staff means nurses, technicians, dietitians, and social workers at this dialysis center. In the last 3 months, how often did the dialysis center staff listen carefully to you? 1 Never 2 Sometimes 3 Usually 4 Always In the last 3 months, how often did the dialysis center staff explain things in a way that was easy for you to understand? 1 Never 2 Sometimes 3 Usually 4 Always In the last 3 months, how often did the dialysis center staff show respect for what you had to say? 1 Never 2 Sometimes 3 Usually 4 Always In the last 3 months, how often did the dialysis center staff spend enough time with you? 1 Never 2 Sometimes 3 Usually 4 Always In the last 3 months, how often did you feel the dialysis center staff really cared about you as a person? 1 Never 2 Sometimes 3 Usually 4 Always In the last 3 months, how often did dialysis center staff make you as comfortable as possible during dialysis? 1 Never 2 Sometimes 3 Usually 4 Always
In the last 12 months, were you as involved as much as you wanted in choosing the treatment for kidney disease that is right for you? 1 Yes 2 No In the last 12 months, were you ever unhappy with the care you received at the dialysis center or from your kidney doctors? 1 Yes 2 No If No, Go to Question 45 In the last 12 months, did you ever talk to someone on the dialysis center staff about this? 1 Yes 2 No If No, Go to Question 45 In the last 12 months, how often were you satisfied with the way they handled these problems? 1 Never 2 Sometimes 3 Usually 4 Always Medicare and your State have special agencies that check the quality of care at this dialysis center. In the last 12 months, did you make a complaint to any of these agencies? 1 Yes 2 No In general, how would you rate your overall health? 1 Excellent 2 Very good 3 Good 4 Fair 5 Poor In general, how would you rate your overall mental or emotional health? 1 Excellent 2 Very good 3 Good 4 Fair 5 Poor Are you being treated for high blood pressure? 1 Yes 2 No Are you being treated for diabetes or high blood sugar? 1 Yes 2 No Are you being treated for heart disease or heart problems? 1 Yes 2 No Are you deaf or do you have serious difficulty hearing? 1 Yes 2 No
Are you blind or do you have serious difficulty seeing, even when wearing glasses? 1 Yes 2 No Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions? 1 Yes 2 No Do you have serious difficulty walking or climbing stairs? 1 Yes 2 No Do you have difficulty dressing or bathing? 1 Yes 2 No Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone, such as visiting a doctor’s office or shopping? 1 Yes 2 No What is the highest grade or level of school that you have completed? 1 No formal education 2 5th grade or less 3 6th, 7th, or 8th grade 4 Some high school, but did not graduate 5 High school graduate or GED 6 Some college or 2-year degree 7 4-year college graduate 8 More than 4-year college degree What language do you mainly speak at home? 1 English 2 Spanish 3 Chinese 4 Samoan 5 Russian 6 Vietnamese 7 Portuguese 8 Some other language (please identify): _______________________ 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
What is your race? (One or more categories may be selected.) 1 White 2 Black or African American 3 American Indian or Alaska Native 4 Asian Indian 5 Chinese 6 Filipino 7 Japanese 8 Korean 9 Vietnamese 10 Other Asian 11 Native Hawaiian 12 Guamanian or Chamorro 13 Samoan 14 Other Pacific Islander Did someone help you complete this survey? 1 Yes 2 No Thank you. Please return the completed survey in the postage-paid envelope. Who helped you complete this survey? 1 A family member 2 A friend 3 A staff member at the dialysis center 4 Someone else (please print): ________________________ How did that person help you? Check all that apply. 1 Read the questions to me 2 Wrote down the answers I gave 3 Answered the questions for me 4 Translated the questions into my language 5 Helped in some other way (please print): ________________________ Thank you. Please return the survey in the enclosed envelope to: VENDOR’S NAME STREET ADDRESS 1 STREET ADDRESS 2 CITY, STATE, ZIP