Form
Approved
OMB No. 0935-0118
Exp. Date XX/XX/20XX
Proxy 2010
A Survey About Diabetes Care
The care of people with diabetes is an important concern of the U.S. Department of Health and Human Services. We would appreciate it if you would take a few minutes to answer the following questions on the care your family member received for his or her diabetes. Your participation is voluntary and all of the 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 for
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 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. In the questions below, “(NAME)” refers to the person listed in the box on the front page.
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. Has (NAME) ever been told by a doctor or other health professional that he/she has 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 (NAME)’s 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
(NAME) 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 (NAME)’s 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 (NAME) have an eye exam in which his/her pupils were dilated? This would have made (NAME) 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 (NAME) have his/her 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 (NAME) get a flu vaccination (shot or nasal spray)? [CHECK ALL THAT APPLY]
During 2009 1
During 2008 2
During 2007 3
Before 2007 4
Never 00
7. Has (NAME)’s diabetes caused problems with his/her kidneys?
Yes 1
No 2
8. Has (NAME)’s diabetes caused problems with his/her eyes that needed to be treated by an ophthalmologist?
Yes 1
No 2
9. Is (NAME)’s diabetes being treated by modifying his/her diet?
Yes 1
No 2
10. Is (NAME)’s diabetes being treated by medications taken by mouth?
Yes 1
No 2
11. Is (NAME)’s diabetes being treated with insulin injections?
Yes 1
No 2
12. During the last 12 months, has (NAME) learned how to take care of his/her diabetes?
Yes 1
No (skip Q 13) 2
13. Which of the following methods has (NAME) used to learn to take care of his/her diabetes? [CHECK ALL THAT APPLY]
Talking
to a doctor/health professional within
his/her primary care practice 1
Talking
to a doctor/health professional
not
in his/her 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 is (NAME) in taking care of his/her 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
Who completed the survey for the person named on the front page?
What is your relationship to the person named on the front page?
Data Year 2009
10-231
| File Type | application/msword |
| Author | Westat Westat |
| Last Modified By | wcarroll |
| File Modified | 2009-08-12 |
| File Created | 2009-07-20 |