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Attachment D. Crosswalk of Item Differences by Questionnaire Version
This attachment crosswalks the survey item differences between the existing 2025 Medicare Health Outcomes Survey Instrument and the proposed
HOS Field Test Questionnaires Version A and Version B.
2025 Health Outcomes Survey
1. In general, would you say your health is:
1
Excellent
2
Very good
3
Good
4
Fair
5
Poor
Field Test Version A
No change
2. The following items are about activities you No change
might do during a typical day. Does your
health now limit you in these activities? If
so, how much?
a. Moderate activities, such as moving a
table, pushing a vacuum cleaner,
bowling, or playing golf
Field Test Version B
No change
N/A
2. The following items are about
activities you might do during a
typical day. Does your health now
limit you in these activities? If so,
how much?
Revised, testing alternate
functional activity as a
potential replacement for less
inclusive activities (bowling
and golf).
a. Moderate activities, such as
moving a table, pushing a vacuum
cleaner, or walking at a brisk pace
1
Yes, limited a lot
2
Yes, limited a little
1
Yes, limited a lot
3
No, not limited at all
2
Yes, limited a little
3
No, not limited at all
b. Climbing several flights of stairs
1
Yes, limited a lot
2
Yes, limited a little
3
No, not limited at all
Reason for Change
No change
No change
N/A
2
2025 Health Outcomes Survey
Field Test Version A
3. During the past 4 weeks, have you had any No change
of the following problems with your work
or other regular daily activities as a result
of your physical health?
Field Test Version B
Reason for Change
No change
N/A
No change
N/A
a. Accomplished less than you would like
as a result of your physical health?
1
No, none of the time
2
Yes, a little of the time
3
Yes, some of the time
4
Yes, most of the time
5
Yes, all of the time
b. Were limited in the kind of work or
other activities as a result of your
physical health?
1
No, none of the time
2
Yes, a little of the time
3
Yes, some of the time
4
Yes, most of the time
5
Yes, all of the time
No change
3
2025 Health Outcomes Survey
Field Test Version A
4. During the past 4 weeks, have you had any No change
of the following problems with your work
or other regular daily activities as a result
of any emotional problems (such as
feeling depressed or anxious)?
Field Test Version B
Reason for Change
No change
N/A
No change
N/A
a. Accomplished less than you would like
as a result of any emotional problems
1
No, none of the time
2
Yes, a little of the time
3
Yes, some of the time
4
Yes, most of the time
5
Yes, all of the time
b. Didn't do work or other activities as
carefully as usual as a result of any
emotional problems
1
No, none of the time
2
Yes, a little of the time
3
Yes, some of the time
4
Yes, most of the time
5
Yes, all of the time
No change
4
2025 Health Outcomes Survey
Field Test Version A
5. During the past 4 weeks, how much did
No change
pain interfere with your normal work
(including both work outside the home and
housework)?
1
Not at all
2
A little bit
3
Moderately
4
Quite a bit
5
Extremely
These questions are about how you feel and No change
how things have been with you during the
past 4 weeks. For each question, please give
the one answer that comes closest to the way
you have been feeling.
6. How much of the time during the past 4
weeks:
a. Have you felt calm and peaceful?
Field Test Version B
Reason for Change
No change
N/A
These questions are about how you feel
and how things have been with you
during the past 4 weeks. For each
question, please give the one answer
that comes closest to the way you have
been feeling.
Revised, testing a 5-item
response option as a simpler
alternative to the current 6item response option and to
align with the second item
in this set (Q7).
6. How much of the time during the past
4 weeks:
a. Have you felt calm and peaceful?
1
All of the time
2
Most of the time
1
All of the time
3
A good bit of the time
2
Most of the time
4
Some of the time
3
Some of the time
5
A little of the time
4
A little of the time
6
None of the time
5
None of the time
5
2025 Health Outcomes Survey
b. Did you have a lot of energy?
Field Test Version A
No change
Field Test Version B
b. Did you have a lot of energy?
1
All of the time
1
All of the time
2
Most of the time
2
Most of the time
3
A good bit of the time
3
Some of the time
4
Some of the time
4
A little of the time
5
A little of the time
5
None of the time
6
None of the time
c. Have you felt downhearted
and blue?
No change
c. Have you felt downhearted
and blue?
1
All of the time
1
All of the time
2
Most of the time
2
Most of the time
3
A good bit of the time
3
Some of the time
4
Some of the time
4
A little of the time
5
A little of the time
5
None of the time
6
None of the time
7. During the past 4 weeks, how much of the
time has your physical health or
emotional problems interfered with your
social activities (like visiting with friends,
relatives, etc.)?
1
All of the time
2
Most of the time
3
Some of the time
4
A little of the time
5
None of the time
No change
No change
Reason for Change
Revised, testing a 5-item
response option as a simpler
alternative to the current 6item response option and to
align with the second item in
this set (Q7).
Revised, testing a 5-item
response option as a simpler
alternative to the current 6item response option and to
align with the second item in
this set (Q7).
N/A
6
2025 Health Outcomes Survey
Now, we’d like to ask you some questions
about how your health may have changed.
Field Test Version A
Field Test Version B
Reason for Change
Item removed
Item removed
Removing because this item is
no longer being considered as
a quality measure for Star
Ratings and to reduce the
number of questions on the
survey.
9. Compared to one year ago, how would
Item removed
you rate your emotional problems (such as
feeling anxious, depressed, or irritable) in
general now?
Item removed
Removing because this item is
no longer being considered as
a quality measure for Star
Ratings and to reduce the
number of questions on the
survey.
Earlier in the survey you were asked to
No change
indicate whether you have any limitations in
your activities. We are now going to ask a few
additional questions in this area.
No change
N/A
10. Because of a health or physical problem,
do you have any difficulty doing the
following activities without special
equipment or help from another
person?
8. Because of a health or physical
problem, do you have any difficulty
doing the following activities without
help from another person?
Testing revised item stem to
be more inclusive of those
who use assistive devices and
potentially enhance Physical
Function Activities of Daily
Living (PFADL) measure.
8. Compared to one year ago, how would
you rate your physical health in general
now?
1
Much better
2
Slightly better
3
About the same
4
Slightly worse
5
Much worse
1
Much better
2
Slightly better
3
About the same
4
Slightly worse
5
Much worse
No change but renumbered (Q8)
7
2025 Health Outcomes Survey
a. Bathing
1
No, I do not have difficulty
2
Yes, I have difficulty
3
I am unable to do this activity
b. Dressing
1
No, I do not have difficulty
2
Yes, I have difficulty
3
I am unable to do this activity
c. Eating
1
No, I do not have difficulty
2
Yes, I have difficulty
3
I am unable to do this activity
d. Getting in or out of chairs
1
No, I do not have difficulty
2
Yes, I have difficulty
3
I am unable to do this activity
e. Walking
1
No, I do not have difficulty
2
Yes, I have difficulty
3
I am unable to do this activity
f. Using the toilet
1
No, I do not have difficulty
2
Yes, I have difficulty
3
I am unable to do this activity
Field Test Version A
No change
Field Test Version B
No change
Reason for Change
N/A
8
2025 Health Outcomes Survey
New item
New item
New item
Field Test Version A
9. Are you able to walk briskly for
20 minutes without stopping to
rest?
5
Without any difficulty
4
With a little difficulty
3
With some difficulty
2
With much difficulty
1
Unable to do
Field Test Version B
9. Are you able to walk briskly for 20
minutes without stopping to rest?
5
Without any difficulty
4
With a little difficulty
3
With some difficulty
2
With much difficulty
1
Unable to do
10. Are you able to climb up 5 flights 10. Are you able to climb up 5 flights of
of stairs?
stairs?
5
Without any difficulty
5
Without any difficulty
4
With a little difficulty
4
With a little difficulty
3
With some difficulty
3
With some difficulty
2
With much difficulty
2
With much difficulty
1
Unable to do
1
Unable to do
11. Does your health limit you in
bending, kneeling, or stooping?
11. Does your health limit you in
bending, kneeling, or stooping?
5
Not at all
5
Not at all
4
Very little
4
Very little
3
Somewhat
3
Somewhat
2
Quite a lot
2
Quite a lot
1
Cannot do
1
Cannot do
Reason for Change
New item set; PatientReported Outcomes
Measurement Information
System (PROMIS) items
being tested as a potential
replacement for existing
physical function items, to
evaluate a wider range of
impairment and potentially
enhance the PFADL measure.
New item set; PROMIS items
being tested as a potential
replacement for existing
physical function items, to
evaluate a wider range of
impairment and potentially
enhance the PFADL measure.
New item set; PROMIS items
being tested as a potential
replacement for existing
physical function items, to
evaluate a wider range of
impairment and potentially
enhance the PFADL measure.
9
2025 Health Outcomes Survey
Field Test Version A
Field Test Version B
12. Does your health limit you in
12. Does your health limit you in doing
doing moderate activities, such as
moderate activities, such as moving a
moving a table, pushing a vacuum
table, pushing a vacuum cleaner, or
cleaner, bowling, or playing golf?
walking at a brisk pace?
New item
5
Not at all
5
Not at all
4
Very little
4
Very little
3
Somewhat
3
Somewhat
2
Quite a lot
2
Quite a lot
1
Cannot do
1
Cannot do
13. Does your health now limit you
in doing heavy work around the
house like moving heavy
furniture?
New item
5
Not at all
4
Very little
3
Somewhat
2
Quite a lot
1
Cannot do
Now we are going to ask some questions about No change but renumbered (Q14)
specific medical conditions.
11. Are you blind or do you have serious
difficulty seeing, even when wearing
glasses?
1
Yes
2
No
13. Does your health now limit you in
doing heavy work around the house
like moving heavy furniture?
5
Not at all
4
Very little
3
Somewhat
2
Quite a lot
1
Cannot do
No change but renumbered (Q14)
Reason for Change
New item set; PROMIS items
being testing as a potential
replacement for existing
physical function item, to
evaluate a wider range of
impairment and potentially
enhance the PFADL measure.
Testing 2 versions.
New item set; PROMIS items
being tested as a potential
replacement for existing
physical function items, to
evaluate a wider range of
impairment and potentially
enhance the PFADL measure.
N/A
10
2025 Health Outcomes Survey
12. Are you deaf or do you have serious
difficulty hearing, even with a hearing aid?
1
Yes
2
No
13. Because of a physical, mental, or
emotional condition, do you have serious
difficulty concentrating, remembering, or
making decisions?
1
Yes
2
No
14. 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
15. In the past month, how often did memory
problems interfere with your daily
activities?
1
Every day (7 days a week)
2
Most days (5-6 days a week)
3
Some days (2-4 days a week)
4
Rarely (once a week or less)
5
Never
Field Test Version A
Field Test Version B
Reason for Change
No change but renumbered (Q15)
No change but renumbered (Q15)
N/A
No change but renumbered (Q16)
No change but renumbered (Q16)
N/A
No change but renumbered (Q17)
No change but renumbered (Q17)
N/A
No change but renumbered (Q18)
No change but renumbered (Q18)
N/A
11
2025 Health Outcomes Survey
Has a doctor ever told you that you had:
Field Test Version A
Field Test Version B
Reason for Change
No change but renumbered (Q19)
No change but renumbered (Q19)
N/A
No change but renumbered (Q20)
No change but renumbered (Q20)
N/A
Item removed
Item removed
Removing to limit the number
of survey questions.
Removing had a negligible
impact on case-mix
adjustment.
Item removed
Item removed
Removing to limit the number
of survey questions.
Removing had a negligible
impact on case-mix
adjustment.
Item removed
Item removed
Removing to limit the number
of survey questions.
Removing had a negligible
impact on case-mix
adjustment.
16. Hypertension or high blood pressure
1
Yes
2
No
17. Angina pectoris or coronary artery disease
1
Yes
2
No
18. Congestive heart failure
1
Yes
2
No
19. A myocardial infarction or heart attack
1
Yes
2
No
20. Other heart conditions, such as problems
with heart valves or the rhythm of your
heartbeat
1
Yes
2
No
12
2025 Health Outcomes Survey
21. A stroke
1
Yes
2
No
22. Emphysema, or asthma, or COPD (chronic
obstructive pulmonary disease)
1
Yes
2
No
23. Crohn’s disease, ulcerative colitis, or
inflammatory bowel disease
1
Yes
2
No
24. Osteoporosis, sometimes called thin or
brittle bones
1
Yes
2
No
25. Diabetes, high blood sugar, or sugar in the
urine
1
Yes
2
No
Field Test Version A
Reason for Change
Field Test Version B
Item removed
Item removed
Removing to limit the number
of survey questions.
Removing had a negligible
impact on case-mix
adjustment.
No change but renumbered (Q21)
No change but renumbered (Q21)
N/A
Item removed
Item removed
Removing to limit the number
of survey questions.
Removing had a negligible
impact on case-mix
adjustment.
Item removed
Item removed
Removing to limit the number
of survey questions.
Removing had a negligible
impact on case-mix
adjustment.
No change but renumbered (Q22)
No change but renumbered (Q22)
N/A
13
2025 Health Outcomes Survey
26. Depression
1
Yes
2
No
27. Any cancer (other than skin cancer)
Yes → Go to Question 28
1
No → Go to Question 29
2
28. Are you currently under treatment for:
a. Colon or rectal cancer
1
Yes
2
No
b. Lung cancer
1
Yes
2
No
c. Breast cancer
1
Yes
2
No
d. Prostate cancer
1
Yes
2
No
e. Other cancer (other than skin cancer)
1
Yes
2
No
Field Test Version A
No change but renumbered (Q23)
24. Any cancer (other than skin
cancer)
1
Yes
2
No
Item removed
Field Test Version B
Reason for Change
No change but renumbered (Q22)
N/A
24. Any cancer (other than skin cancer)
Removed skip pattern because
follow-up question (Q28) was
removed.
1
Yes
2
No
Item removed
Removing to limit the number
of survey questions.
Removing this and other items
in this section had a negligible
impact on case-mix
adjustment.
14
2025 Health Outcomes Survey
29. In the past 7 days, how much did pain
interfere with your day to day activities?
1
Not at all
2
A little bit
3
Somewhat
4
Quite a bit
5
Very much
30. In the past 7 days, how often did pain keep
you from socializing with others?
1
Never
2
Rarely
3
Sometimes
4
Often
5
Always
Field Test Version A
Field Test Version B
Reason for Change
Item renumbered (Q25)
Item renumbered (Q25)
N/A
Item renumbered (Q26)
Item renumbered (Q26)
N/A
15
2025 Health Outcomes Survey
Field Test Version A
Field Test Version B
31. Over the past 2 weeks, how often have you 27. Over the past 2 weeks, how often 27. Over the past 2 weeks, how often
been bothered by any of the following
have you been bothered by any of
have you been bothered by any of the
problems?
the following problems?
following problems?
a. Little interest or pleasure in doing things
a. Feeling nervous, anxious or on
edge
a. Feeling nervous, anxious or on
edge
1
Not at all
2
Several days
1
Not at all
1
Not at all
3
More than half the days
2
Several days
2
Several days
4
Nearly every day
3
More than half the days
3
More than half the days
4
Nearly every day
4
Nearly every day
b. Feeling down, depressed, or hopeless
1
Not at all
2
Several days
3
More than half the days
4
Nearly every day
b. Not being able to stop or
control worrying
b. Not being able to stop or control
worrying
1
Not at all
1
Not at all
2
Several days
2
Several days
3
More than half the days
3
More than half the days
4
Nearly every day
4
Nearly every day
c. Little interest or pleasure in
doing things
c. Little interest or pleasure in doing
things
1
Not at all
1
Not at all
2
Several days
2
Several days
3
More than half the days
3
More than half the days
4
Nearly every day
4
Nearly every day
d. Feeling down, depressed, or
hopeless
d. Feeling down, depressed, or
hopeless
1
Not at all
1
Not at all
2
Several days
2
Several days
3
More than half the days
3
More than half the days
4
Nearly every day
4
Nearly every day
Reason for Change
Revised, testing expanded
item to assess a broader array
of mental health conditions
using the PHQ-4.
16
2025 Health Outcomes Survey
32. In general, compared to other people your
age, would you say that your health is:
1
Excellent
2
Very good
3
Good
4
Fair
5
Poor
33. Many people experience leakage of urine,
also called urinary incontinence. In the past
six months, have you experienced leaking
of urine?
1
Yes → Go to Question 34
2
No → Go to Question 37
34. During the past six months, how much did
leaking of urine make you change your
daily activities or interfere with your sleep?
1
A lot
2
Somewhat
3
Not at all
35. Have you ever talked with a doctor, nurse,
or other health care provider about leaking
of urine?
1
Yes
2
No
Field Test Version A
Item removed
Field Test Version B
Item removed
Reason for Change
Removing to reduce the
number of survey questions.
This item is not used for casemix adjustment.
Item renumbered (Q28)
Item renumbered (Q28)
N/A
Item renumbered (Q29)
Item renumbered (Q29)
N/A
Item renumbered (Q30)
Item renumbered (Q30)
N/A
17
2025 Health Outcomes Survey
36. There are many ways to control or manage
the leaking of urine, including bladder
training exercises, medication, and surgery.
Have you ever talked with a doctor, nurse,
or other health care provider about any of
these approaches?
1
Yes
2
No
37. In the past 12 months, did you talk with a
doctor or other health provider about your
level of exercise or physical activity? For
example, a doctor or other health provider
may ask if you exercise regularly or take
part in physical exercise.
1
Yes → Go to Question 38
2
No → Go to Question 38
3
Field Test Version A
Field Test Version B
Reason for Change
Item renumbered (Q31)
Item renumbered (Q31)
N/A
Item renumbered (Q32)
Item renumbered (Q32)
N/A
Item renumbered (Q33)
Item renumbered (Q33)
N/A
I had no visits in the past 12
months → Go to Question 39
38. In the past 12 months, did a doctor or other
health provider advise you to start, increase
or maintain your level of exercise or
physical activity? For example, in order to
improve your health, your doctor or other
health provider may advise you to start
taking the stairs, increase walking from 10
to 20 minutes every day or to maintain your
current exercise program.
1
Yes
2
No
18
2025 Health Outcomes Survey
39. A fall is when your body goes to the ground
without being pushed. In the past 12
months, did you talk with your doctor or
other health provider about falling or
problems with balance or walking?
1
Yes
2
No
3
Field Test Version B
Reason for Change
Item renumbered (Q34)
Item renumbered (Q34)
N/A
Item renumbered (Q35)
Item renumbered (Q35)
N/A
Item renumbered (Q36)
Item renumbered (Q36)
N/A
Item renumbered (Q37)
Item renumbered (Q37)
N/A
I had no visits in the past 12
months
40. Did you fall in the past 12 months?
1
Yes
2
No
41. In the past 12 months, have you had a
problem with balance or walking?
1
Yes
2
No
42. Has your doctor or other health provider
done anything to help prevent falls or treat
problems with balance or walking? Some
things they might do include:
• Suggest that you use a cane or walker.
• Suggest that you do an exercise or
physical therapy program.
• Suggest a vision or hearing test.
1
Yes
2
No
3
Field Test Version A
I had no visits in the past 12
months
19
2025 Health Outcomes Survey
N/A
Field Test Version A
Field Test Version B
Reason for Change
38. In the past 12 months,
has a doctor or other
health professional
talked with you about
your diet or eating
habits?
38. In the past 12 months, has a
doctor or other health
professional provided advice
about your diet or eating
habits?
New item; adapted from the
Behavioral Risk Factor
Surveillance System (BRFSS)
as a potential cross-sectional
quality measure.
1
1
Yes
No
I had no visits in the
past 12 months
2
3
39. In the past 12 months,
has a doctor or other
health professional
talked with you about
your alcohol use?
N/A
No
I had no visits in the
3
past 12 months
2
39. In the past 12 months, has a
doctor or other health
professional provided advice
about your alcohol use?
1
1
Yes
No
I had no visits in the
3
past 12 months
2
43. During the past month, on average, how
many hours of actual sleep did you get at
night? (This may be different from the
number of hours you spent in bed.)
1
Less than 5 hours
2
5 – 6 hours
3
7 – 8 hours
4
9 or more hours
Item renumbered (Q40)
Yes
Yes
New item; adapted from the
Behavioral Risk Factor
Surveillance System (BRFSS)
as a potential cross-sectional
quality measure.
No
I had no visits in the
3
past 12 months
2
Item renumbered (Q40)
N/A
20
2025 Health Outcomes Survey
44. During the past month, how would you
rate your overall sleep quality?
Field Test Version A
Field Test Version B
Reason for Change
Item renumbered (Q41)
Item renumbered (Q41)
N/A
Item renumbered (Q42)
Item renumbered (Q42)
N/A
46. How tall are you without shoes on, in feet
Item renumbered (Q43)
and inches? Please fill in both feet and
inches, for example: 5 feet 00 inches, or 5
feet 04 inches (if 1/2 inch, please round up).
Item renumbered (Q43)
N/A
Item removed
Question removed as per SPD15. We plan to implement the
updated SPD-15 race and
ethnicity question. We are
using this to ensure
comparability of responses
across mail, telephone, and
web administrations in
particular for an older
population.
1
Very Good
2
Fairly Good
3
Fairly Bad
4
Very Bad
45. How much do you weigh in pounds (lbs.)?
lbs.
feet
Inches
47. Are you of Hispanic, Latino/a or Spanish
origin? (One or more categories may be
selected)
1
2
No, not of Hispanic, Latino/a, or
Spanish origin
Yes, Mexican, Mexican American,
Chicano/a
3
Yes, Puerto Rican
4
Yes, Cuban
5
Yes, another Hispanic, Latino/a, or
Spanish origin
Item removed
21
Field Test Version
A
44. What is your
48. What is your race? (One or more categories
race or ethnicity?
may be selected)
Please mark one or
more.
White
01
2025 Health Outcomes Survey
02
Black or African American
03
American Indian or Alaska Native
04
Asian Indian
05
Chinese
06
Filipino
07
Japanese
08
Korean
09
Vietnamese
10
Other Asian
11
Native Hawaiian
12
Guamanian or Chamorro
13
Samoan
14
Other Pacific Islander
49. What language do you mainly speak at
home?
1
English
2
Spanish
3
Chinese
4
Russian
7
Some other language (please specify)
_________________
American Indian or
01
Alaska Native
Asian
02
Black or African
03
American
Hispanic or Latino
04
Middle Eastern or
05
North African
06
07
Native Hawaiian or
Pacific Islander
White
No change but renumbered (Q45)
Field Test Version B
Reason for Change
44. What is your race or
ethnicity? Please mark
one or more.
Updated according to SPD-15.
We plan to implement the
updated SPD-15 race and
ethnicity question. We are
using this to ensure
comparability of responses
across mail, telephone, and
web administrations in
particular for an older
population.
American Indian or
01
Alaska Native
Asian
02
Black or African
03
American
Hispanic or Latino
04
Middle Eastern or North
05
African
06
07
Native Hawaiian or
Pacific Islander
White
No change but renumbered (Q45)
N/A
22
2025 Health Outcomes Survey
50. What is your current marital status?
Field Test Version A
Field Test Version B
Reason for Change
No change but renumbered (Q46)
No change but renumbered (Q46)
N/A
51. What is the highest grade or level of school No change but renumbered (Q47)
that you have completed?
No change but renumbered (Q47)
N/A
Item removed
Removing item because some
stakeholders and respondents
have noted they are
uncomfortable divulging
information that may affect
their personal security. This
item is not used for case-mix
adjustment.
1
Married
2
Divorced
3
Separated
4
Widowed
5
Never married
1
2
8th grade or less
Some high school, but did not
graduate
3
High school graduate or GED
4
Some college or 2-year degree
5
4-year college graduate
6
More than a 4-year college degree
52. Do you live alone or with others? (One or
more categories may be selected)
1
Alone
2
With spouse/significant other
3
With children/other relatives
4
With non-relatives
5
With paid caregiver
Item removed
23
2025 Health Outcomes Survey
53. Where do you live?
Field Test Version A
Field Test Version B
Reason for Change
Item removed
Item removed
Removing to limit the number
of survey questions.
Removing the items had a
negligible impact on case-mix
adjustment.
54. Is the house or apartment you currently live Item removed
in:
Item removed
Removing to limit the number
of survey questions.
Removing the item had a
negligible impact on case-mix
adjustment.
Item removed
Removing to limit the number
of survey questions.
Removing the item had a
negligible impact on case-mix
adjustment.
1
2
House, apartment, condominium, or
mobile home Go to Question 54
Assisted living or board and care
home Go to Question 54
3
Nursing home
4
Other
1
2
3
4
5
Go to Question 55
Go to Question 55
Owned or being bought by you
Owned or being bought by someone
in your family other than you
Rented for money
Not owned and one in which you live
without payment of rent
None of the above
55. Who completed this survey form?
1
2
3
4
Person to whom survey was
addressed STOP HERE
Family member or relative of person
to whom the survey was addressed
Go to Question 56
Friend of person to whom the survey
was addressed Go to Question 56
Professional caregiver of person to
whom the survey was addressed
Go to Question 56
Item removed
24
2025 Health Outcomes Survey
56. Did someone help you complete this
survey? If so, please fill in that person’s
name.
DO NOT enter the name of the person to
whom this survey was addressed.
Please print clearly.
First Name: _____________________
Last Name: _____________________
Field Test Version A
Item removed
Field Test Version B
Item removed
Reason for Change
Removing item because
survey vendors noted the
instruction is frequently
ignored by respondents and
questionnaires are returned
with unneeded PII.
| File Type | application/pdf |
| File Title | Attachment D. Crosswalk of Item Differences by Questionnaire Version |
| Author | Centers for Medicare & Medicaid Services (CMS) |
| File Modified | 2025-08-07 |
| File Created | 2025-08-07 |