Form 10-10138 Monthly Script Mentor Questions

[Type the document title]

OMB No. 2900-XXXX
Estimated Burden: 1473 hours
Expiration Date: 03/31/2018

Using Peer Mentors to Support PACT Team Efforts to Improve Diabetes –

PACT Demo Lab VISN 4

VA Form 10-10138

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average 2-45 minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this telephone/mail survey will lead to improvements in the quality of service delivery by helping to by evaluating the effects of the VA PACT initiative and by testing new, innovative strategies for patient care that can be spread if proven effective. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

Monthly Calls

CV 1. Date enrolled: / /

CV2. Date of phone call: / /

Check in: ______1 month _______3 month

Hello this is ________________________________ from the diabetes study at the VA.

Is ___________________________________ there?

- No, when might be a good time for me to call back to get____________________?

- Yes, would this be an ok time to talk for 5 minutes?

-No, when should I call back_________________________

-Yes, great.

1. Did you talk to __________________ in the past 30 days? Yes 1/No 0

1a. If no, why not? ______________________________________________________

1b. If Yes. How many times did you talk to them? ___________________________

2. How did it go?____________________________________________________________

3. Do you have any concerns?_________________________________________________

4. Did you use the take home sheets to guide your conversation?______________________

4a. [if no] Why not?____________________________________________________

4b. [if yes] Did you find it helpful? How so? __________________________________

5. What were some of the topics you discussed?____________________________________

6. What were some of the barriers they felt they were facing to getting their diabetes in control?

____________________________________________________________________________

7. What are his/her goals?______________________________________________________

8. Were you able to help him/her come up with a realistic plan?_________________________

9. Are they able to follow the plan?_______________________________________________

10. Is there something you would like to discuss in regards to mentoring?_________________

10a. [if yes] What is it_____________________________________________________

10b. follow-up until all issues raised__________________________________________

11. [If spoke to mentee 4 or more times]

Would you like to schedule a time to come and pick up your voucher for talking to your mentee 4 or more times?____________________________________________________________________

(We do not send payments by mail)

Thank you, I will call again next month.