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pdfForm Approved
OMB No. 0920-0904
Exp. Date 11/30/2014
N
W
E
SEARCH
For Diabetes in Youth
* Note: Fonts are Times New Roman & Smudger LET Plain.
Initial Participant Survey
Young Adult Version
This survey is to be filled out by the person
(18 years older) who has diabetes.
Public reporting burden of this collection of information is
estimated to average 10 minutes per response, including the
time for reviewing instructions, searching existing data sources,
gathering and maintaining 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 Reports
Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta,
Georgia 30333; ATTN: PRA (0920-0904)
SEARCH 3 Registry Study — Initial Participant Survey (Young Adult Verison) revised 5-14-12
SEARCH for Diabetes in Youth
We want to learn more about children and young people
who have diabetes. You can help us to do that by filling
out these questions. You may ask your Parent or Legal
Guardian to help you.
1. What is today’s date? ______ /______ /___________
Month
Day
Year
For example, if today is May 1, 2011, write in 05/01/2011
q Female 2 q Male
2.
What is your sex?
3.
Has a doctor or nurse ever told you that you have diabetes?
1q
2
1
YES. Turn the page and continue on to question 4.
q NO. STOP. Please turn to page 9 and complete this information.
Please mail the survey to us in the stamped envelope.
Thank You
for filling out these questions.
1
We will ask you some questions about when you first got diabetes, and how you
treat your diabetes. Please answer the questions as best you can. If you do not know
N
the answer to a question, leave it blank.
4. What is your birthdate?
5.
Month
Day
Year
When were you first told by a doctor or a nurse that you had diabetes?
This means when you were told about your diabetes diagnosis.
6.
______ /______ /___________
______ /______ /___________
Month
Day
W
Year
How did you first find out that you had diabetes?
(Check yes or no for each question)
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
I was thirsty, had to pee a lot, or got sick very quickly
I found out that I had diabetes when I had a school physical or at a
regular check-up.
I found out that I had diabetes when my blood sugar was checked at a
health fair or at school.
SEF
I found out that I had diabetes when I was pregnant and the diabetes
did not go away after the pregnancy.
I found out I had diabetes when I was pregnant but the diabetes went
away after the pregnancy.
If none of the responses above apply to you, please write on the lines below how you first found out that
you had diabetes.
2
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
7.
What type of diabetes did the doctor or nurse tell you that you have?
(please check one box)
1q
Type 1 diabetes, IDDM, juvenile diabetes
2q
Type 2 diabetes, NIDDM
3q
Maturity onset diabetes of youth (MODY)
4q
Other type of diabetes, please specify ___________________________________________
5q
I don’t know
* Note: Fonts are Times New Roman
SEARCH for Diabetes in Youth
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8.
Has a doctor or nurse told you that your diabetes was caused by:
(please check Yes or No for each question)
8a. cystic fibrosis?
8b. cancer or medicine to treat cancer?
8c. another medicine?
1q
E
Yes
1q
2q
Yes
No
2q
1q
Yes
2q
No
No
If Yes, what was the medicine?
9.
Since you’ve had diabetes, have you ever taken insulin?
9a. Were you taking insulin two weeks after diagnosis ?
9b. Are you taking insulin now?
1q
Yes
2q
1q
Yes
1q
2q
Yes
No (If no, skip to question 10)
2q
No
No
10. How else do you take care of your diabetes now? Do you use:
(please check Yes or No for each question)
SEARCH
For Diabetes in Youth
10a. Diabetes tablets (pills)?
10b. Diet (meal plans)?
10c. Exercise?
10d. Any treatments other than insulin, pills, diet, or exercise (What?):
1q
Yes
1q
1q
Yes
2q
Yes
2q
2q
No
No
No
11. Are you Spanish/Hispanic/Latino?
(Mark X in the “No” box if not Spanish/Hispanic/Latino)
q No, not Spanish/Hispanic/Latino
q Yes, Puerto Rican
q Yes, Mexican, Mexican Am., Chicano
q Yes, Cuban
q Yes, other Spanish/Hispanic/Latino – Print group:
12. What is your race? Mark one or more races to indicate what you consider yourself to be.
q White q Black, African American
q American Indian or Alaska Native; Print name of enrolled or principal tribe:
q Asian Indian
q Japanese
q Native Hawaiian
q Chinese
q Korean
q Guamanian or Chamorro
q Filipino
q Vietnamese
q Samoan
q Other Asian; Print race:
q Other Pacific Islander; Print race:
w Roman & Smudger LET Plain.
SEARCH for Diabetes in Youth
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13. When you first got diabetes, where did you live?
City
State
Zip Code
County
14. When you first got diabetes, were you in the Army, Navy, Air Force, Marines, or Coast Guard?
1q
Yes
2q
No
3q
Don’t know
Now we have some questions about your current height and weight.
15. What is your current weight?
____________ Pounds,
or ____________ Kilograms
16. What is your current height?
____________ Feet ____________ Inches
q Don’t know
or ____________ Centimeters
q Don’t know
Now we would like to ask you a few questions about whether or not other people in your
family have diabetes.
Please provide information about your mother, father, brothers and sisters. This refers to your
biological or natural parents (not step-parents or adoptive parents) and your full or half brothers
and sisters, not those who were adopted or step brothers or step sisters.
Please include information for relatives who are living and those who are deceased.
17. Does your biological mother have diabetes?
1q
Yes
2q
No
3q
Don’t know
17a. q If Yes, how old was she when she was diagnosed with diabetes?
_______ years
q Don’t know
18. Did your biological mother have any form of diabetes when she was pregnant with you?
This includes Type 1 diabetes, Type 2 diabetes, gestational diabetes, or other types of diabetes.
1q
Yes
2q
No
3q
Don’t know
19. Does your biological father have diabetes?
Yes
2q
No
3q
Don’t know
19a. q If Yes, how old was he when he was diagnosed with diabetes?
4
1q
_______ years
q Don’t know
SEARCH for Diabetes in Youth
20. Do you have any full or half brothers?
Yes
2q
No
3q
Don’t know
(If No or I don’t know, skip to question 21).
20a. If Yes, how many full or half brothers do you have?
1q
_______ brothers
20b. If Yes, how many full or half brothers have diabetes?
_______ brothers
21. Do you have any full or half sisters?
Yes
2q
No
3q
Don’t know
(If No or I don’t know, skip to question 22)
21a. If Yes, how many full or half sisters do you have?
1q
_______ sisters
21b. If Yes, how many full or half sisters have diabetes?
_______ sisters
Now we would like to learn a bit about your health insurance and the health care services.
22. What kind of health insurance plan do you have now?
(Answer Yes or No for each question).
22a. Medicaid/Medicare/State-funded/other Federally-funded
22b. Private insurance, through employer
22c. Private insurance, purchased on your own
22d. Military
22e. School-based insurance
22f. Tribe/Indian Health Service
22g. Any other or type unknown
22h. None
SEARCH for Diabetes in Youth
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
5
23. What kind of health insurance plan did you have when you were diagnosed with diabetes?
(Answer Yes or No for each question).
23a. Medicaid/Medicare/State-funded/other Federally-funded
23b. Private insurance, through employer
23c. Private insurance, purchased on your own
23d. Military
23e. School-based insurance
23f. Tribe/Indian Health Service
23g. Any other or type unknown
23h. None
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
Yes
No
1q
2q
24. Who do you usually go to for most of your care related to diabetes?
(Please check only one response).
q Pediatrician
2 q Family practice or internal medicine physician
3 q Pediatric endocrinologist/diabetologist (diabetes specialist)
4 q Adult endocrinologist/diabetologist (diabetes specialist)
5 q Another type of physician
6 q Other health care professional (nurse, nurse practitioner, physician assistant,
1
6
7q
certified diabetes educator or other)
Unsure
The next few questions are related to the education and household income of your family.
25. What is the highest degree or level of school that your mother/guardian, father/guardian, and you
have completed?
Mother/
guardian
Father/
guardian
25a. Any education less than a high school graduate, no diploma
or GED
1q
1q
1q
25b. High school graduate, (high school diploma) or equivalent
(for example, GED)
2q
2q
2q
25c. Business/technical school, associate degree (AA, AS) or some
college
3q
3q
3q
25d. Bachelor degree (for example, BA, AB, BS) (4-year)
4q
4q
4q
25e. Master degree (for example MA, MS, MEng, Med., MSW)
5q
5q
5q
25f. Professional or doctorate degree (for example, MD, DDS, JD,
PhD, EdD)
6q
6q
6q
25g. Don’t know
7q
7q
7q
You
26. Which of these categories best describes the total income of all persons living in your Parent/
Guardian’s household for the past 12 months?
(check only one category)
1q
Less than $5,000
6q
$35,000 through $49,999
2q
$5,000 through $11,999
7q
$50,000 through $74,999
3q
$12,000 through $15,999
8q
$75,000 through $99,999
4q
$16,000 through $24,999
9q
$100,000 and greater
5q
$25,000 through $34,999
10 q
Don’t know
27. How many people are living in your Parent/Guardian’s household?
27a. Total number of people ________
27b. Number of children (less than 18) ________
27c. Number of adults ________
Of the number of adults, how many bring income into the household? ________
SEARCH for Diabetes in Youth
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28. Were you born in the United States?
1q
Yes (If Yes, go to question 29)
2q
No
28a. If no: In what country were you born? Write in country of birth.
28b. In what year did you come to the United States to live?
3q
Write in year.
Don’t know / prefer not to say
29. Was your mother born in the United States?
1q
Yes (If Yes, go to question 30)
2q
No
29a. If no: In what country was your mother born? Write in country of birth.
q Don’t know country
29b. In what year did your mother come to the United States to live?
3q
Write in year.
q Don’t know year
Don’t know / prefer not to say
30. Was your father born in the United States?
1q
Yes (If Yes, go to question next page)
2q
No
30a. If no: In what country was your father born? Write in country of birth.
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3q
q Don’t know country
30b. In what year did your father come to the United States to live?
q Don’t know year
Don’t know / prefer not to say
Write in year.
Contact Information
We would like to be able to reach you to let you know about other parts of the SEARCH study. To do
this, we would like to have the best address and phone number where we can reach you.
A.
What is your name?
First
Middle
Last
Are there any other names that you use?
Other first names
Other last names
B.
What are your parent/guardian’s names?
First
Middle
Last
First
Middle
Last
SEARCH for Diabetes in Youth
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C.
What is the best address, email and phone number to send mail or call?
P.O.Box
City
State
Email address
Street
Apt#
Zip Code
Phone number (best)
-
-
area code
Is this:
extension
q Home q Work q Cellular Phone q Other
Phone number (other)
-
-
area code
Is this:
q
extension
Home
Phone number (other)
q
Work
-
q
Cellular Phone
-
area code
Is this:
q
Other
extension
q Home q Work q Cellular Phone q Other
What is the best time to call? q morning
May we contact you over the weekend?
May we contact you at work?
Who lives at this address? (check yes or no for each one)
I do
1q
Yes
2q
No
My Father
1q
Yes
2q
No
My Mother
1q
Yes
2q
No
My Spouse
1q
Yes
2q
No
Other
1q
Yes
2q
No
Do you usually speak:
1q
English
2q
Spanish
3q
Some other language
Specify:_______________________________________________________
10
q afternoon q evening
q Yes q No
q Yes q No
SEARCH for Diabetes in Youth
Alternate Contact Information
As a part of this study, we may be contacting you in the future. Please provide us with the names,
addresses, phone numbers and email addresses of two people who could contact you if your
address or phone number changes.
Contact #1:
First Name
Middle Name
Last Name
Relationship
P.O.Box
City
State
Email address
Phone number (best)
Street
Apt#
Zip Code
-
-
area code
Phone number (other)
extension
-
-
area code
Phone number (other)
-
area code
SEARCH for Diabetes in Youth
extension
-
extension
11
Contact #2:
First
Middle
Last
Relationship
P.O.Box
City
State
Email address
Street
Zip Code
Phone number (best)
-
-
area code
Phone number (other)
extension
-
-
area code
Phone number (other)
extension
-
-
area code
Thank You for filling out this survey.
Please mail it to us in the stamped, pre-addressed envelope.
If you have lost the envelope, please send it to the address below.
12
Apt#
extension
FOR STUDY USE ONLY
Patient ID Number
Site
Sub-site
Sequential ID
Date Completed
Month
Day
Year
Mode of Administration
Date Reviewed
Month
In Person
Day
Month
Day
Telephone
Mailed
CATI
Reviewer Code
Year
Date Entered
Completed by
Data Entry Code
Year
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SEARCH
For Diabetes in Youth
SEARCH for Diabetes in Youth
* Note: Fonts are Times New Roman & Smudger LET Plain.
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11-0457 search form english young adult
| File Type | application/pdf |
| File Modified | 2012-08-28 |
| File Created | 2012-08-21 |