Form #2 Attachment 23 -- HC Diabetes SAQ - Self

Draft

Form Approved

OMB #0935-0118

_{Exp. Date}

Self 2013

_{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:

/ /

_{MONTH DAY YEAR}

PID:

1

12345

_RUID:

When you have completed the survey, please fold it, seal it with this label, ^ and place it in the envelope provided.

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. 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.

The Agency for Healthcare Research and Quality and The Centers for Disease Control and Prev ention of the U.S. Department of Health and Human Services

A Survey About Your Diabetes Care

^{Instructions: Answer each question by marking one box}  ^{or filling in a number when} necessary. 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?

^{MARK  ONE.}

Yes ..........................................................

Please continue.

No ...........................................................

Thank you for your time. This survey is complete.

3. Which of the following year(s) did a doctor or other health professional check your feet for any sores or irritations?

^{MARK  ALL THAT APPLY.}

During 2013 ...................................... During 2012 ...................................... During 2011...................................... Before 2011 ......................................

_{Never ................................................}

2. During 2011, 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 to monitor the glucose level of diabetes over a period of several months. The A1C test is usually done in a lab, hospital, or doctor's office although a home kit containing materials for one or two tests is now available. The A1C test is not the same as a Home Glucose Monitoring test which is used at home to monitor glucose levels on a daily or weekly basis,

and needs supplies of disposable test strips.)

If you had this blood test, fill in

NUMBER OF TIMES ......................

Did not have A1C blood test ........... Don't know ...................................... Never ..............................................

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.

^{MARK  ALL THAT APPLY.}

During 2013 ...................................... During 2012 ...................................... During 2011 ...................................... Before 2011 ...................................... Never ................................................

5. Which of the following year(s) did you have your blood cholesterol checked? MARK _ ALL THAT APPLY.

During 2013 ...................................... During 2012 ...................................... During 2011 ...................................... Before 2011 ...................................... Never ................................................

6. Which of the following year(s) did you

get a flu vaccination (shot or nasal spray)? MARK _ ALL THAT APPLY.

During 2013 ........................................... During 2012 ........................................... During 2011 ........................................... Before 2011 ........................................... Never .....................................................

7. Has your diabetes caused problems with your kidneys?

Yes ......................................................... No ..........................................................

8. Has your diabetes caused problems

with your eyes that needed to be treated by an ophthalmologist?

Yes ......................................................... No ..........................................................

9. Is your diabetes being treated by modifying your diet?

Yes ......................................................... No ..........................................................

10. Is your diabetes being treated by medications taken by mouth?

Yes ......................................................... No ..........................................................

11. Is your diabetes being treated with insulin injections?

Yes ......................................................... No ..........................................................

12. During the last 12 months, have you learned how to take care of your diabetes?

Yes ......................................................... No (Skip to Q 14) ...................................

13. Which of the following methods have you used to learn to take care of your diabetes? MARK _ ALL THAT APPLY.

Talking to a doctor/health professional within your primary care practice ............

Talking to a doctor/health professional not in your primary care practice ............

Telephone call with a

health professional ................................. Reading about it on the Internet ............ Taking a group class .............................. Other (specify)

14. How confident are you in taking care of your diabetes?

Not confident at all ................................. Somewhat confident .............................. Confident ............................................... Very confident ....................................... Refused .................................................

_{Don't know ............................................}

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:} MONTH DAY YEAR

_{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 2012

13-230

4

3

12345