Vendor Participation Form
Home Health Care CAHPS Survey - Vendor Participation Form
This application is to be completed by survey vendors who wish to become approved to conduct the Home Health Care CAHPS (HHCAHPS) Survey. Click here to access a pdf version of the blank form.

Note: Home Health Agencies should not complete this form.

Before completing this application, survey vendors interested in becoming an approved HHCAHPS Survey vendor should review the vendor participation requirements included in the HHCAHPS Protocols and Guidelines Manual. The HHCAHPS Protocols and Guidelines Manual is available on the HHCAHPS website at https://homehealthcahps.org.

Vendors that do not have any Home Health Agency clients after two years from the date of their interim approval will have their approval rescinded. If you wish to maintain your approved vendor status at that time, you must reapply. To reapply, you must update your online vendor application, attend and successfully complete the next Introduction to the Home Health Care CAHPS Survey webinar sessions, and attend the annual Update training sessions.

You will need to 'Save' each section before moving to the next section. To save a section, click on the 'Save' button at the top or bottom of the screen. Note: All text boxes have a limit of 2,000 characters.

When you have completed all parts of the application and are ready to submit it, please click on the 'Submit' button on the lower left of the screen. You will receive a confirmation email with a link to your application that you may use to access your application and make updates at any time. Each time you make an update to your application, you must Submit the application again.

All survey vendors must designate a survey administrator (see Section VIII of the vendor participation form below), and this individual must also complete, sign, notarize and submit a vendor consent form.


    •  The following general information should be filled out about the applicant organization.
      1. Vendor Organization Information 
      Organization Name *
      Mailing Address 1
      Mailing Address 2
      City
      State *
      ZIP Code
      Telephone number
      Fax number
      Website address

      2. Contact Person 
      First Name, Middle Initial, Last Name *
      Title
      Degree/License (e.g., BA, PhD, MBA, PMA)
      Mailing Address 1:
      Mailing Address 2:
      City:
      State: *
      ZIP Code:
      (Area Code) Telephone number:
      (Area Code) Fax number:
      Email address *




    • As indicated at the top of this form, interested vendors should review the vendor participation requirements included in the
      HHCAHPS Survey Protocols and Guidelines Manual which is available on the HHCAHPS website. Survey vendors should note
      the following:
      • Any organization that owns, operates, or provides staffing for a home health agency will not be permitted to
        administer its own HHCAHPS Survey or administer the survey on behalf of any other home health agencies.
        The following types of organizations are not eligible to administer the HHCAHPS Survey (as an approved HHCAHPS
        survey vendor):
        • organizations or divisions within organizations that own or operate a home health agency or provide home
          health services, even if the division is run as a separate entity to the home health agency;
        • organizations that provide telehealth, monitoring of home health patients, or teleprompting services for
          home health agencies; and
        • organizations that provide staffing to home health agencies for providing care to home health patients,
          whether personal care aides or skilled services staff.
      • Applicant organization must conduct all HHCAHPS Survey-related operations within the United States, due
        to the need to be compliant with required HHCAHPS oversight activities, including site visits to vendor's
        location.
      Survey vendors must meet the minimum set of business requirements described in the Protocols and Guidelines Manual to be
      eligible to be an approved HHCAHPS Survey vendor. Please respond to the questions below by providing the requested
      response or checking the appropriate response box. Completion and submission of this application certifies that your
      organization has read and meets these requirements.
      If your organization is part of an organization that owns, operates, or provides staffing for a home health agency or
      if your organization does not meet the minimum business requirements, please do not complete and submit this application.
      Relevant Business Experience 
      1. Number of Years Organization Has Been in Business:
      2. Number of Years the Organization has been Conducting Surveys of Individuals:

      A "survey of individuals" is defined as the collection of data from individuals selected by statistical sampling methods and the data collected are used for statistical purposes. Applicant must be able to demonstrate that it has conducted surveys of individuals responding about their own experiences, not of individuals responding on behalf of a business or organization, and applicant must be able to demonstrate that a statistical sampling process was used in the conduct of previously or currently conducted surveys.

      Note: Applicant organization must have conducted surveys where a sample of individuals was selected for at least 2 years. If staff within the applicant organization have relevant experience obtained while in the employment of a different organization, that experience may not be counted toward the 2-year minimum of survey experience.

      The following examples of data collection activities would not satisfy the requirement of valid survey experience for vendors as defined for the HHCAHPS Survey and these would not be considered as part of the experience that HHCAHPS will require:

      • polling questions administered to trainees or participants of training sessions or educational courses, seminars, or workshops;
      • focus groups, cognitive interviews, or any other qualitative data collection activities;
      • surveys of fewer than 600 individuals;
      • surveys conducted that did not involve using statistical sampling methods;
      • Internet or Web-based surveys; and
      • Interactive Voice Recognition Surveys.
      3. Survey Experience (indicate number of years of experience conducting surveys using each data collection mode):
      Years:
      Years:
      Years:

      Indicate Mode that you are Appying for
      Check the mode(s) that you are applying for and indicate whether you will be using a subcontractor for that mode. Note that a subcontractor does not have to be an approved HHCAHPS vendor to be considered as a subcontractor.
      Applying for: Using a Subcontractor(s)?
      1. Telephone Only
      2. Mail Only
      3. Mixed Mode (Mail and Telephone)
      If you are using a subcontractor, indicate the number of years of experience that the subcontractor has been conducting surveys, for that mode(s)
      Telephone Only Years:
      Mail Only Years:
      Mixed Mode (Mail and Telephone) Years:

      Survey Capability and Capacity 
      The items below indicate that the applicant organization has the capability and capacity to collect and process all survey-related data for the selected survey administration mode(s) following standardized procedures and guidelines. Applicant must currently possess all required facilities, equipment and systems to implement the HHCAHPS Survey and have available to work on the project staff with requisite training, qualifications and experience.

      Personnel - Applicant Organization 
      1. Can your organization designate an HHCAHPS Survey Project Manager with survey administration and management experience?
      2. Does your organization employ and have available to work on the HHCAHPS Survey a Sampling Manager with sample frame development and sample selection experience, including experience using different sampling methods (simple random sampling, proportionate stratified ramdon sampling, and disproportionate stratified random sampling)?
      3. Does your organization have computer programmers capable of processing data and preparing data files for electronic submission?
      4. Please explain any "No" responses above:

       

      Facilities and Systems - Applicant Organization 
      1. Has physical facilities for processing and storage of all data collection materials.
      2. Has computers and computer software and any other equipment needed for survey implementation (e.g., scanners, printers, computer-assisted telephone interviewing [CATI] or alternative electronic system, data entry system).
      3. Has an electronic survey management system to track fielded surveys throughout the data collection period.
      4. Has call center or telephone bank facilities for telephone survey implementation.
      5. Is capable of offering and manning a toll-free telephone number to receive and address calls from survey participants, required for ALL modes.
      6. Has a secure commercial work environment for receiving, processing, and storing hard copy questionnaires or hard copy sample files from home health agencies that protects the confidentiality of patient response data and personal identifying information (e.g., hard copy documents must be stored in a locked file cabinet, room, or building).
      7. Has appropriate systems in place to protect the confidentiality of electronic data received from home health agencies AND survey data received from patients. Systems may include storing electronic files in password-protected locations, use of firewalls, use of strong password policies, use of data encryption software for sending private health information, and use of proper software for virus and spyware protection. This would also include limiting access to data only to personnel who require access and administrators.
      8. Please explain any "No" responses above:

       




    • Survey vendors must meet the following requirements to be eligible to become a vendor on the Home Health
      Care CAHPS Survey. Please respond to the questions below by providing the requested response or checking the
      appropriate response box. Your answers certify that your organization has read and meets these requirements.

      Sample Frame Development and Sample Selection - Applicant Organization 
      1. Has ability to construct a sample frame that includes all patients who meet survey eligibility criteria.
      2. Will be able to work with individual home health agencies to obtain patient data for sampling and is able to accept the data electronically or on hard copy, depending on how the home health agency provides it.
      3. Is able to convert sampling information from paper to electronic file format so that quality control checks can be performed on both the sample frame and the selected sample by the Home Health Care CAHPS Survey Oversight Team.
      4. Is able to draw the sample following specified guidelines and adequately document the process.
      5. Please explain any "No" responses above:

       

      Survey Administration Requirements, By Mode 
      Please provide your responses for the modes you are applying for. If you are not applying for a given mode, select "Not Applying for this Mode."
      Mail Only Survey Administration
      Vendor has the capability to obtain and verify addresses of sampled patients, print professional-quality survey instruments and materials, assign a unique sample identification number (SID) to each sampled patient and match the SID to the status/outcome for each sample member, assemble and mail survey materials, receive and process (key entry or scanning) completed questionnaires received, track and identify non-respondents for follow-up mailing, provide a toll-free customer support line and respond to calls within 1 to 2 business days, and assign final status codes to describe the final result of work on each sampled case.
      Telephone Only Survey Administration
      Vendor has the capability to obtain and verify telephone numbers, develop computer programs for computer-assisted telephone interview instruments, collect data using computer-assisted telephone interviewing (CATI) or alternative electronic system, schedule call backs to non-respondents at varying times of the day/week, assign a unique sample identification number (SID) to each sampled patient and match SIDs to the status/outcome for each sample member, provide a toll-free customer support line and respond to calls within 1 to 2 business days, and assign final status codes to reflect the results of attempts to obtain completed interview with sampled cases.
      Mixed Mode Survey Administration
      Vendor has the capability to adhere to all Mail Only and Telephone Only Survey Administration requirements described above, and track cases from mail survey through telephone follow-up activities.
      Please explain any "No" responses above:

       

      Data Processing and File Submission - Applicant Organization 
      1. Has capability to scan or key and develop data files and edit and clean data according to standard protocols.
      2. Has capability to submit data electronically in the specified format (XML) via the Home Health Care CAHPS Survey secured website.
      3. Has capability to follow all data cleaning and data submission rules, including:
      a. verification that data are de-identified and contain no duplicate cases.
      b. verification that the XML template is correctly formatted and contains the proper data headers and data records.
      c. ability to work with CMS's contractor to resolve data and data file submission problems.
      4. Please explain any "No" responses above:

       

      Quality Assurance 
      Vendor must have experience incorporating quality assurance into all sampling, data collection, data processing, and data file construction activities as noted below. Vendor agrees to participate in all required training and quality assurance activities necessary to ensure the successful implementation of the Home Health Care CAHPS Survey.
      1. Vendor must be able to incorporate well-documented quality control procedures (as applicable) for:
      a. In-house training of staff involved in survey operations.
      b. Sample frame construction and sample selection.
      c. Printing, mailing and recording of receipt of incoming survey questionnaires.
      d. Telephone administration of survey.
      e. Coding and editing of survey data and survey-related materials.
      f. Scanning or keying survey data.
      g. Preparation of final person-level data files for submission.
      h. All other functions and processes that affect the administration of the Home Health Care CAHPS Survey.
      2. Vendor agrees to the following documentation requirements:
      a. Will keep electronic or hard copy files of individuals trained, training dates.
      b. Will maintain electronic or hard copy records of interviewers monitored (for telephone administration).
      c. Will maintain electronic or hard copy records of mailing dates.
      d. Will maintain other documentation necessary to allow the Home Health Care CAHPS Survey Oversight team to review procedures implemented, should the vendor be selected for a site visit.
      e. Will maintain documentation of actions required (and taken) as a result of any decisions made during site visits by the Oversight Team.
      3. Vendor agrees to adhere to specified procedures, attend survey training, and participate in quality assurance activities:
      a. Vendor agrees to review and follow all procedures described in the Home Health Care CAHPS Survey Protocols and Guidelines Manual as are relevant for their selected survey modes.
      b. Vendor must attend all CMS Introduction and Update training sessions. Failure to do so will jeopardize their standing as an approved vendor.
      c. Vendor agrees to participate in any conference calls and site visits requested by the Oversight Team as part of overall quality monitoring activities. Vendor agrees to provide documentation as requested for site visits and conference calls, including but not limited to staff training records, telephone interviewer monitoring records, sample frame development documentation, and data file construction documentation.
      4. Please explain any "No" responses above:

       




    • Please indicate the name of the Project Manager assigned to the Home Health Care CAHPS Survey, if known:
      Please indicate the name of the Sampling Manager assigned to the Home Health Care CAHPS Survey, if known:




    • List of Subcontractors 
      Note: Survey vendors should promptly update the List of Subcontractors as subcontractors are added or deleted.
      Add new Subcontractor Refresh
      #Subcontractor  
      No Vendor Subcontractors listed.




    • List of Contracted Home Health Agencies 
      Vendor should submit an Update to this form whenever home health agencies are added or removed from the list of active contracts.
      Add new Home Health Agency Refresh
      #Agency  
      No Home Health Agencies listed.



    • All vendors who wish to become approved vendors for the Home Health Care CAHPS Survey must adhere
      to the following requirements. The vendor must:
      1. Participate in both the Introduction to the Home Health Care CAHPS Survey Training and any subsequent Update trainings. The vendor's Project Manager must attend the training; it is strongly advised that the vendor's Sampling and Data Managers also attend.
      2. Review and Follow the Home Health Care CAHPS Survey Protocols and Guidelines Manual and the Data Submission Manual.
      3. Develop and Submit a Quality Assurance Plan, following guidelines described in the Home Health Care CAHPS Survey Protocols and Guidelines Manual. Update the plan as information contained within it changes.
      4. Participate and cooperate in all oversight activities conducted by the Home Health Care CAHPS Survey Oversight Team, including but not limited to conference calls and site visits, as deemed necessary.
      5. Acknowledge that review of and agreement with these Participation Requirements is necessary for participation and public reporting of Home Health Care CAHPS Survey results.


    • I certify that:
      I have reviewed and agree to meet the Participation Rules for the Home Health Care CAHPS Survey Survey.
      The statements herein are true, complete, and accurate to the best of my knowledge, and I accept the obligation to comply with the Home Health Care CAHPS Survey Survey Vendor Requirements.
      Authorized Representative
      Name
      Title
      Organization
      Date
      HyperLink




    • All vendors must designate a Survey Administrator to whom the Home Health CAHPS Survey Coordination Team will issue credentials to access the private side of the Home Health Care CAHPS Survey website. The Administrator will be responsible for the following:
      1. Designating another individual within the organization as the backup Administrator.
      2. Completing or approving each staff member who will have access to the Home Health Care CAHPS Survey website as a non-administrator user.
      3. Granting individual non-administrator users access to specific functions on the Home Health Care CAHPS Survey website.
      4. Updating non-administrator user information on the Home Health Care CAHPS Survey website based on staff changes/assignments.
      5. Removing access or approving the removal of access for users who are no longer authorized to access the private side of the Home Health Care CAHPS Survey website.
      6. Serving as the main point of contact with the Home Health Care CAHPS Survey Data Center.
      7. Notifying the Home Health Care CAHPS Survey Data Coordination Team if his/her role as the Home Health Care CAHPS Survey Administrator will no longer be valid and identifying his/her successor.
      8. Maintaining the confidentiality of all data that are submitted to the Home Health Care CAHPS Survey Data Center.

      In the space below, please indicate the name, title, and e-mail address of the person whom you are designating as the Home Health Care CAHPS Survey Administrator for your organization. This email address will be used as the login credentials for the survey administrator, so it is very important to enter it accurately.

      HOME HEALTH CARE CAHPS SURVEY ADMINISTRATOR

      Name
      Title
      Phone
      Email *



       
* Required