Form No number No number DDI Patient Survey

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

DDI Patient Survey

Public reporting burden of this collection of information is estimated to average 20 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 CDC/ATSDR Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-xxxx). Do not send the completed form to this address.

Battelle Memorial Institute is conducting a survey for the Centers for Disease Control and Prevention to better understand people’s attitude towards screening for diabetes. This survey has three parts. First, we provide some background on diabetes including potential complications, risk factors and prevention. Second, we start the survey with questions about your background. Finally, we will describe some hypothetical options for diabetes screening and ask you to select the one that you like best.

Type 2 diabetes mellitus is a common and serious disease in the U.S. It is estimated that 18 million Americans have diabetes but 5.2 million are undiagnosed. Having type 2 diabetes increases your risk for many serious complications. Some complications of Type 2 diabetes include:

• heart disease with a higher risk of heart attacks;

• nerve damage with a higher risk of amputations;

• eye disease with a higher risk of blindness; and

• kidney disease with a higher risk of kidney failure.

Although diabetes is serious, it can be controlled especially if it is diagnosed early. Good control of diabetes means healthy levels for blood sugar, blood pressure and cholesterol so that your risk for the complications will be lower. If you are diagnosed with diabetes, you might be able to achieve control through diet and exercise. For most people, if their doctor believes it will help you control your blood sugar, blood pressure and cholesterol, medication will be prescribed as well.

If people with diabetes are not diagnosed, they delay getting proper treatment and this increases their chances of developing some of the complications. Nearly one third of all people with type 2 diabetes do not know that they have the disease. There are many factors that place people at higher risk for diabetes including: age, being overweight, having a family history of diabetes, whether you exercise regularly as well as being a member of particular race or ethnic groups. If you have high risk for diabetes, then your doctor may recommend that you get screening.

Survey Questions

1. What is your age? ____ years

If age is less than 40, stop the interview.

2. Are you male or female?

 Male

 Female

3. Have you ever been told by your doctor that you have diabetes?

 Yes

 Yes, female told only during pregnancy (skip to Question 4)

 No (skip to Question 4)

 Don’t know or not sure (skip to Question 4)

3b. How was your diabetes diagnosed?

 Screening and diagnosis as part of the Diabetes Detection Initiative

 Regular doctor check-up

 Had symptoms

 Don’t know

End survey here for people who answered yes to 3 and not only during pregnancy.

4. Have you ever been screened for diabetes?

 Yes

 No (skip to Question 5)

 Don’t know (skip to Question 5)

4b. When was the last time you were screened for diabetes?

 Within last year

 1 to 5 years ago

 More than 5 years ago

5. Have you ever been told by your doctor, nurse or health professional that you have high blood pressure?

 Yes

 No

6. Have you ever been told by your doctor, nurse or health professional that you have high cholesterol?

 Yes

 No

7. For women, have you had a baby weighing more than 9 pounds at birth?

 Yes

 No

8. Do you have a sister or brother with diabetes?

 Yes

 No

9. Do you have a parent(s) with diabetes?

 Yes

 No

Please stop answering these questions and alert the interviewer that you need to complete the screening options “game” now. You will return to these questions when you are done. Thank you.

10. About how much do you weigh without shoes? _____ (pounds)

11. About how tall are you without shoes? ____ feet ____ inches

12. Are you Hispanic or Latino?

 Yes

 No

13. Which one or more of the following would you say is your race?

	Check all that apply
a. American Indian or Alaska Native	
b. Asian	
c. Black or African American	
d. Native Hawaiian or Other Pacific Islander	
e. White	

14. If more than one response is marked for 13, which one of these groups would you say best represents your race?

	Check one
a. American Indian or Alaska Native	
b. Asian	
c. Black or African American	
d. Native Hawaiian or Other Pacific Islander	
e. White	

15. What is your current employment status?

a. Employed for wages		(skip to Question 16)
b. Self-employed		(skip to Question 16)
c. Out of work for more than 1 year		(skip to Question 17)
d. Out of work for less than 1 year		(skip to Question 16)
e. Homemaker		(skip to Question 17)
f. Student		(skip to Question 17)
g. Retired		(skip to Question 17)
h. Unable to work		(skip to Question 17)

16. What is your hourly wage including tips, bonuses and commissions before deducting taxes?

a. Less than $7.50	
b. Between $7.50 and $9.99	
c. Between $10 and $14.99	
d. Between $15 and $19.99	
e. Between $20 and $29.99	
f. At least $30 or more	

17. How many adults and children live in your household? ____ adults ___children

18. What is your annual household income from all sources?

a. Less than $5,000	
b. Between $5,000 and $10,000	
c. Between $10,000 and $14,999	
d. Between $15,000 and $19,999	
e. Between $20,000 and $34,999	
f. Between $35,000 and $49,999	
g. At least $50,000	

19. Do you have any kind of health care coverage? Please check all that apply.

 Medicare

 Medicaid

 Champus, VA or military health insurance

 Private health insurance

 None

20. How much did you spend on health care? Only include what was spent for yourself and do not include what was spent for other family members.

1. Did you pay for anything at this health clinic over the last year?

 Yes, then how much? __________  No, nothing

 Don’t know

2. Do you expect to pay for anything at this health clinic for this visit?

 Yes, then how much? __________  No, nothing

 Don’t know

3. Is the amount for this visit typical?

 Yes,  No _____ then what do you usually pay at this health clinic for a usual visit?

 Nothing, usually pay ______________

 Don’t know

4. Did you pay for other health cares expenses including, prescription medicine, hospital visits, emergency room visits or other health clinics over the last year?

 Yes, then how much? __________  No, nothing

 Don’t know

21. When you go to this health clinic, how much time does it usually take to get there?

________ Hours __________ Minutes

22. How do you usually get to the clinic (check all that apply)?

	Check all that apply
a. Car	
b. Bus	
c. Train	
d. Taxi	
e. Ferry	
f. Walk	

22b. If you use a car,

How many miles for a roundtrip? ______

How much do you usually pay to park? ______

22c. If you use a bus, train, taxi or ferry, how much does it usually cost for the roundtrip fare(s)? ______

23. If employed, do you miss work when you go to the clinic?

 All of the time

 Most of the time

 Some of the time

 A little of the time

 None of the time or not employed

24. When you go to the clinic, do you need someone else to take you there?

 All of the time

 Most of the time

 Some of the time

 A little of the time

 None of the time

25. If you have young children, do you need to arrange for child care?

 All of the time

 Most of the time

 Some of the time

 A little of the time

 None of the time or no young children

25b. If yes, do you usually need to pay someone and what does that cost per visit? _____________

26. In the last twelve months, how many times did you visit the health clinic? _______

27a. What do you think are your chances of developing type 2 diabetes in the next ten years?

a. Very unlikely	
b. Somewhat unlikely	
c. Somewhat likely	
d. Very likely	

27b. Compared to others, what do you think are your chances of developing type 2 diabetes in the next ten years?

a. Very unlikely compared to other people my age	
b. Somewhat unlikely compared to other people my age	
c. About the same as others my age	
d. Somewhat likely compared to other people my age	
e. Very likely compared to other people my age	

Thank you for your time and effort in participating in this survey. Please return the completed survey to the interviewer.