Form 4 Gatekeeper

SAMPLE: GATEKEEPER REVIEW

OMB No. 0925-0530

Exp. Date 06/30/07

Diabetes and CAM Fact Sheet Survey

Thank you for agreeing to review the Diabetes and CAM fact sheet. Once you’ve read the fact sheet, please take a few minutes to answer the questions below. Your responses will help ensure that the fact sheet is as useful as possible for patients.

1. Do you discuss CAM use with your patients?

• Always

• Usually

• Occasionally

• Never

2. On average, how many patients with type 2 diabetes do you see in a week?

• 0-5

• 6-10

• 11-15

• More than 15

3. Please rate your level of agreement with the following statements:

	Strongly Disagree	Disagree	Neither disagree nor agree	Agree	Strongly agree	Not applicable
The fact sheet design is attractive.
The fact sheet is at an appropriate reading level for my patients.
The fact sheet content is appropriate for my patients.
I would distribute this fact sheet to my patients.

3. Do you have any suggestions for improving the fact sheet?

• Yes

• No

4a. If yes, what are your suggestions?

Thank you for your time and participation. If you have any additional comments or questions, please contact us at [email protected] or toll-free at 1-866-644-6226.

Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0468). Do not return the completed form to this address.

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