Home Health Care Cahps Survey Hha Survey Administrator Consent Form printable pdf download

Home Health Care CAHPS Survey

HHA Survey Administrator Consent Form

The individual within the home health agency who completes this form will be considered the Home

Health Care CAHPS Survey Administrator for that Agency. This form must be signed and dated in the

presence of a notary public, notarized, and mailed to:

ATTN: Vanessa Thornburg

Home Health Care CAHPS Survey

RTI International

3040 Cornwallis Road

P.O. Box 12194

Research Triangle Park, NC 27709

I, _________________________ (Print Administrator name), acknowledge and accept the role

and all of the responsibilities of the Home Health Care CAHPS Survey Administrator for

____________________________ (Print Name of HHA). In this role I will be responsible for:

•

Registering as the Home Health Care CAHPS Survey Administrator on the Home Health

Care CAHPS Survey website at

•

Designating another individual within the organization as the backup Administrator.

•

Completing and/or approving each staff member who will have access to the Home Health

Care CAHPS Survey website as a non-administrator user.

•

Granting individual non-administrator users access to specific functions on the Home Health

Care CAHPS Survey website.

•

Updating non-administrator user information on the Home Health Care CAHPS Survey

website based on staff changes/assignments.

•

Removing access and/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.

•

Serving as the main point of contact with the Home Health Care CAHPS Survey Data

Center.

•

Notifying the Home Health Care CAHPS Survey Data Coordination Team if my role as the

Home Health Care CAHPS Survey Administrator will no longer be valid and identifying my

successor.

By signing this form, I also authorize that my name and e-mail address can be given out as the

Administrator for my organization to individuals who request account access for my

organization.

Administrator Signature: _______________________________ Title: ______________________

Phone Number: (______) ______________________E-mail address: ______________________

Home Health Agency Name: ______________________________________________________

HHA CCN: __________________________

Notary Public Signature: ___________________________Stamp:

Notary Public Date: ____________________

Home Health Care Cahps Survey Hha Survey Administrator Consent Form

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