Form
Approved
OMB No. 0935-0118
Exp. Date XX/XX/20XX
Self 2010
A Survey About Your Diabetes Care
The care of people with diabetes is an important concern of the U.S. Department of Health and Human Services. Please take a few minutes to answer the following questions on the care you received for your diabetes. Your participation is voluntary and all of your answers will be kept confidential to the extent permitted by law. If you have any questions about this survey, please call Alex Scott at 1-800-945-MEPS (6377).
This survey should be completed by
NAME:
DOB: PID:
RUID:
When you have completed the survey, please fold it, seal it with this label, and place it in the envelope provided.
The Agency for Healthcare Research and Quality and
The Centers for Disease Control and Prevention of the
U.S.
Department of Health and Human Services
Your
responses will be kept confidential to the extent permitted by law,
including AHRQ’s confidentiality statute, 42 USC 299c-3(c).
That law requires that information collected for research conducted
or supported by AHRQ that identifies individuals or establishments
be used only for the purpose for which it was supplied unless you
consent to the use of the information for another purpose. Public
reporting burden for this collection of information is estimated to
average 3
minutes per response, the estimated time required to complete
the survey. 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: AHRQ Reports Clearance Officer Attention: PRA,
Paperwork Reduction Project (0935-0118) AHRQ,
540 Gaither Road, Room # 5036, Rockville, MD 20850.
A Survey About Your Diabetes Care
Instructions: Answer every question by checking one box or filling in a number as indicated. If you are unsure about how to answer a question, please give the best answer you can.
A health professional could be a general doctor, a specialist doctor, a nurse practitioner, a physician assistant, a nurse, or anyone else you would see for health care.
1. Have you ever been told by a doctor or other health professional that you have diabetes or sugar diabetes? (CHECK ONE)
Yes 1
Please continue.
No 2
Thank you for your time.
This
survey is complete.
2. During 2009, how many times did a doctor, nurse, or other health professional check your blood for glycosylated hemoglobin or “hemoglobin A-one-C”?
(A1C
is a blood test that is primarily done to monitor the glucose level
of diabetics. Please note that this is a blood test that has to be
done in a lab, hospital, or doctor’s office; this is NOT
a test that you can perform at home.)
If
you had this blood test, fill in
NUMBER
OF TIMES __
Did not have A1C blood test 96
Don’t know 98
Never 00
3. Which of the following year(s) did a doctor or other health
professional check your feet for any sores or irritations?
[CHECK
ALL THAT APPLY]
During 2010 1
During 2009 2
During 2008 3
Before 2008 4
Never 00
4. Which of the following year(s) did you have an eye exam in which your pupils were dilated? This would have made you temporarily sensitive to bright light. [CHECK ALL THAT APPLY]
During 2010 1
During 2009 2
During 2008 3
Before 2008 4
Never 00
5. Which of the following year(s) did you have your blood cholesterol
checked?
[CHECK
ALL THAT APPLY]
During 2010 1
During 2009 2
During 2008 3
Before 2008 4
Never 00
6. Which of the following year(s) did you get a flu vaccination (shot or nasal spray)? [CHECK ALL THAT APPLY]
During 2010 1
During 2009 2
During 2008 3
Before 2008 4
Never 00
7. Has your diabetes caused problems with your kidneys?
Yes 1
No 2
8. Has your diabetes caused problems with your eyes that needed to be treated by an ophthalmologist?
Yes 1
No 2
9. Is your diabetes being treated by modifying your diet?
Yes 1
No 2
10. Is your diabetes being treated by medications taken by mouth?
Yes 1
No 2
11. Is your diabetes being treated with insulin injections?
Yes 1
No 2
12. During the last 12 months, have you learned how to take care of your diabetes?
Yes 1
No (skip Q 13) 2
13. Which of the following methods have you used to learn to take care of your diabetes? [CHECK ALL THAT APPLY]
Talking
to a doctor/health professional within
your primary care practice 1
Talking
to a doctor/health professional
not
in your primary care practice 2
Telephone
call with a
health
professional 3
Reading
about it on the Internet 4
Taking
a group class 5
14. How confident are you in taking care of your diabetes?
Not confident at all 1
Somewhat confident 2
Confident 3
Very confident 4
Don’t know/Refused 0
Thank you for taking the time to complete this important survey.
Please remember to fold it, seal it, and place it in the envelope provided.
Date completed
If this survey was not completed by the person named on the front page, who completed the survey?
What is this person’s relationship to the person named on the
front page?
What is the reason the person named on the front page did not complete the survey himself/herself?
Data Year 2009
10-230
| File Type | application/msword |
| Author | Westat Westat |
| Last Modified By | wcarroll |
| File Modified | 2009-08-12 |
| File Created | 2009-07-20 |