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* 1. Our records show that you are now in the health plan. Is that right?

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* 2. What is the name of your health plan?

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* 3. In the last 12 months, did you have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor’s office?

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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 thought you needed?

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* 5. In the last 12 months, not counting the times you needed care right away, did you make any appointments for your health care at a doctor’s office or clinic?

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* 6. In the last 12 months, not counting the times you needed care right away, how often did you get an appointment for your health care at a doctor’s office or clinic as soon as you thought you needed?

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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 go to a doctor’s office or clinic to get health care for yourself?

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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?

  10 Best health care possible 9 8 7 6 5 4 3 2 1 0 Worst health care possible
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* 9. A personal doctor is the one you would see if you need a check-up, want advice about a health problem, or get sick or hurt. Do you have a personal doctor?

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* 10. In the last 12 months, how many times did you visit your personal doctor to get care for yourself?

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* 11. In the last 12 months, how often did your personal doctor explain things in a way that was easy to understand?

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* 12. In the last 12 months, how often did your personal doctor listen carefully to you?

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* 13. In the last 12 months, how often did your personal doctor show respect for what you had to say?

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* 14. In the last 12 months, how often did your personal doctor spend enough time with you?

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* 15. 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?

  10 Best personal doctor possible 9 8 7 6 5 4 3 2 1 0 Worst personal doctor possible
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* 16. 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 try to make any appointments to see a specialist?

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* 17. In the last 12 months, how often was it easy to get appointments with specialists?

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* 18. How many specialists have you seen in the last 12 months?

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* 19. We want to know your rating of the specialist you saw 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 the specialist?

  10 Best specialist possible 9 8 7 6 5 4 3 2 1 0 Worst specialist possible
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* 20. In the last 12 months, did you try to get any kind of care, tests, or treatment through your health plan?

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* 21. In the last 12 months, how often was it easy to get the care, tests, or treatment you thought you needed through your health plan?

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* 22. In the last 12 months, did you try to get information or help from your health plan’s customer service?

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* 23. In the last 12 months, how often did your health plan’s customer service give you the information or help you needed?

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* 24. In the last 12 months, how often did your health plan’s customer service staff treat you with courtesy and respect?

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* 25. In the last 12 months, did your health plan give you any forms to fill out?

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* 26. In the last 12 months, how often were the forms from your health plan easy to fill out?

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* 27. 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?

  10 Best health plan possible 9 8 7 6 5 4 3 2 1 0 Worst health plan possible
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* 28. In general, how would you rate your overall health?

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* 29. In the past 12 months, have you seen a doctor or other health provider 3 or more times for the same condition or problem?

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* 30. Is this a condition or problem that has lasted for at least 3 months? Do not include pregnancy or menopause.

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* 31. Do you now need or take medicine prescribed by a doctor? Do not include birth control.

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* 32. Is this medicine to treat a condition that has lasted for at least 3 months? Do not include pregnancy or menopause.

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* 33. What is your age?

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* 34. Are you male or female?

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* 35. What is the highest grade or level of school that you have completed?

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* 36. Are you of Hispanic or Latino origin or descent?

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* 37. What is your race? Please choose one or more.

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* 38. Did someone help you complete this survey?

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* 39. How did that person help you? Mark all that apply.

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