CAHPS® Dental Plan Survey Template

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

Yes

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

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* 3. In the last 12 months, did you go to a dentist’s office or clinic for care?

Yes

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* 4. A regular dentist is one you would go to for check-ups and cleanings or when you have a cavity or tooth pain. Do you have a regular dentist?

Yes

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* 5. Have you seen your regular dentist in the last 12 months?

Yes

No, I’ve seen someone else

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* 6. In the last 12 months, how often did your regular dentist explain things in a way that was easy to understand?

Never

Sometimes

Usually

Always

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* 7. In the last 12 months, how often did your regular dentist listen carefully to you?

Never

Sometimes

Usually

Always

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* 8. In the last 12 months, how often did your regular dentist treat you with courtesy and respect?

Never

Sometimes

Usually

Always

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* 9. In the last 12 months, how often did your regular dentist spend enough time with you?

Never

Sometimes

Usually

Always

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* 10. Using any number from 0 to 10, where 0 is the worst regular dentist possible and 10 is the best regular dentist possible, what number would you use to rate your regular dentist?

	10 Best regular dentist possible	9	8	7	6	5	4	3	2	1	0 Worst regular dentist possible
.	. 10 Best regular dentist possible	. 9	. 8	. 7	. 6	. 5	. 4	. 3	. 2	. 1	. 0 Worst regular dentist possible

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* 11. In the last 12 months, how often did the dentists or dental staff do everything they could to help you feel as comfortable as possible during your dental work?

Never

Sometimes

Usually

Always

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* 12. In the last 12 months, how often did the dentists or dental staff explain what they were doing while treating you?

Never

Sometimes

Usually

Always

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* 13. In the last 12 months, how often were your dental appointments as soon as you wanted?

Never

Sometimes

Usually

Always

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* 14. If you needed to see a dentist right away because of a dental emergency in the last 12 months, did you get to see a dentist as soon as you wanted?

I did not have a dental emergency in the last 12 months

Definitely yes

Somewhat yes

Somewhat no

Definitely no

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* 15. If you tried to get an appointment for yourself with a dentist who specializes in a particular type of dental care (such as root canals or gum disease) in the last 12 months, how often did you get an appointment as soon as you wanted?

I did not try to get an appointment with a specialist dentist for myself in the last 12 months

Never

Sometimes

Usually

Always

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* 16. In the last 12 months, how often did you have to spend more than 15 minutes in the waiting room before you saw someone for your appointment?

Never

Sometimes

Usually

Always

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* 17. If you had to spend more than 15 minutes in the waiting room before you saw someone for your appointment, how often did someone tell you why there was a delay or how long the delay would be?

Never

Sometimes

Usually

Always

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* 18. Using any number from 0 to 10, where 0 is the worst dental care possible and 10 is the best dental care possible, what number would you use to rate all of the dental care you personally received in the last 12 months?

	10 Best regular dentist possible	9	8	7	6	5	4	3	2	1	0 Worst regular dentist possible
.	. 10 Best regular dentist possible	. 9	. 8	. 7	. 6	. 5	. 4	. 3	. 2	. 1	. 0 Worst regular dentist possible

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* 19. In the last 12 months, how often did your dental plan cover all of the services you thought were covered?

Never

Sometimes

Usually

Always

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* 20. In the last 12 months, did your dental plan cover what you and your family needed to get done?

Definitely yes

Somewhat yes

Somewhat no

Definitely no

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* 21. In the last 12 months, did you try to find out how your dental plan works by calling their 800 number, visiting their website, or reading printed materials?

Yes

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* 22. In the last 12 months, how often did the 800 number, written materials, or website provide the information you wanted?

Never

Sometimes

Usually

Always

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* 23. In the last 12 months, did you use any information from the dental plan to help you find a new dentist?

Yes

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* 24. Did this information help you find a dentist you were happy with?

Definitely yes

Somewhat yes

Somewhat no

Definitely no

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* 25. Using any number from 0 to 10, where 0 is extremely difficult and 10 is extremely easy, what number would you use to rate how easy it was for you to find a dentist?

	10 Extremely easy	9	8	7	6	5	4	3	2	1	0 Extremely difficult
.	. 10 Extremely easy	. 9	. 8	. 7	. 6	. 5	. 4	. 3	. 2	. 1	. 0 Extremely difficult

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

Yes

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

Never

Sometimes

Usually

Always

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

Never

Sometimes

Usually

Always

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* 29. Using any number from 0 to 10, where 0 is the worst dental plan possible and 10 is the best dental plan possible, what number would you use to rate your dental plan?

	10 Best dental plan possible	9	8	7	6	5	4	3	2	1	0 Worst dental plan possible
.	. 10 Best dental plan possible	. 9	. 8	. 7	. 6	. 5	. 4	. 3	. 2	. 1	. 0 Worst dental plan possible

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* 30. Would you say that your dental plan is worth the cost?

Definitely yes

Somewhat yes

Somewhat no

Definitely no

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* 31. Would you recommend this dental plan to people who want to join?

Definitely yes

Probably yes

Probably no

Definitely no

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* 32. In general, how would you rate the overall condition of your teeth and gums?

Excellent

Very good

Good

Fair

Poor

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* 33. What is your age?

18 to 24

25 to 34

35 to 44

45 to 54

55 to 64

65 to 74

75 or older

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* 34. Are you male or female?

Male

Female

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

8th grade or less

Some high school, but did not graduate

High school graduate or GED

Some college or 2-year degree

4-year college graduate

More than 4-year college degree

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

Yes, Hispanic or Latino

No, Not Hispanic or Latino

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

White

Black or African-American

Asian

Native Hawaiian or other Pacific Islander

American Indian or Alaska Native

Other

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* 38. Did someone help you complete this survey?

Yes

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

Read the questions to me

Wrote down the answers I gave

Answered the questions for me

Translated the questions into my language

Helped in some other way