| Question |
Code |
Response |
| Demographic |
| 1. Site Name (MUST be the Org code that is provided by the DPRP) |
SITE_CODE |
|
|
| 2. Please select from the list the type of organization that best describes your site. |
SITE_DESC |
|
|
| If you answer "Other," please specify. |
|
| 3. Please list the full address of your site. |
SITE_LOC |
|
|
| 4. Was this site still active in Year 3? If yes, continue to question 6. If no, answer question 5 and stop. |
SITE_ACTIVE |
|
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| 5. If the site was not active in Year 3, please provide reasons. |
CLOSE_WHY |
|
|
| 6. Grant Year |
GRANT_YR |
|
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| 7. Fiscal Year |
FIS_YR |
|
|
| Intervention Description |
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|
|
| 9. For the current grant year, did your site change the DPP curriculum from the previous year? If no, skip to question 12. |
CURRICUL_Y2 |
|
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| 10. If Yes to question 9, which DPP curriculum are you currently using at this site? |
CURRICUL_Y3 |
|
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| 11. If Yes to question 9, why did the program change the DPP curriculum from the previous year? |
CUR_CHANGE |
|
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| 12. For the current grant year, did the program recruit NEW participants? If no, skip to question 14. |
PAR_NEW |
|
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| 13. If yes to question 13, please select from the list demographic characteristics of NEW PARTICIPANTS. Please select ALL that apply. |
PAR_CHAR |
|
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|
|
| If you answer "Other," please specify. |
|
| 14. Is there purposeful targeting of NEW disparate or vulnerable populations during recruitment for program participation at the site level? If so, what populations are targeted? Please select ALL that apply. |
SVULPOP |
|
|
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|
|
|
|
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|
|
| If you answer "Other," please specify. |
|
| 15. Were there any NEW places from which National DPP participants were recruited? Please select ALL that apply. |
RECRUTPL |
|
|
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|
|
| If you answer "Other," please specify. |
|
| 16. Did you use any NEW recruitment methods (i.e., materials or campaigns, from healthcare/insurance company patient rosters, etc.) to identify and recruit new participants? Please select ALL that apply. |
SRECMETH |
|
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|
|
| 17. Were there any NEW referral sources (i.e., clinics, employers/worksites, state health departments, physicians, health centers, private organizations, non-profits, insurers, etc.). Please select ALL that apply. |
OREFLSOR |
|
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|
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|
| If you answer "Other," please specify. |
|
| 18. How have you adapted the lifestyle change program to address the specific cultural needs or preferences of one or more of your targeted populations? Please select ALL that apply. |
SITE_ADAPT |
|
|
|
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|
|
| If you answer "Other," please specify. |
|
| 19. Was there any change in policy resulting in a new financing/reimbursement mechanism? If so, what entities have implemented the change in policy resulting in a new financing/reimbursement mechanism? Please select ALL that apply. |
SCOVPOL_Y2 |
|
|
|
|
| If you answer "Other," please specify. |
|
| 20. What was the policy that was changed? Please select ALL that apply. |
SCOVPOL_Y3 |
|
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|
| If you answer "Other," please specify. |
|
| 21. Do you charge participants for the program? If so, and if you are able to report this data, how much do you charge on average per participant? |
PAR_PROGCOST |
|
|
|
| 22. Is any participation or completion incentive offered to participants? If so, what are the incentive items? Please select ALL that apply. |
SITE_INCENT |
|
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| If you answer "Other," please specify. |
|
| Resources |
|
|
|
| 23. Please indicate from the list of primary resources necessary for program start-up and implementation (e.g., partnerships/coalition, in-kind contributions, etc.). Please select ALL that apply. |
SITE_RES |
|
|
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|
| If you answer "Other," please specify. |
|
| 24. In the current grant year, please list the number of and types of locations where classes are offered, and zip codes for all class locations (e.g., employer worksite, community health centers, clinic/practice, community centers, YMCAs, gyms, church, other non-profit, etc.)? Please select ALL that apply. |
PROGPLAC |
|
Location Type |
Number of Classes offered at this Location |
Location Zip Code |
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| If you answer "Other," please specify. |
|
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|
| 25. For the current grant year, was there any change from the previous grant year regarding how lifestyle coaches were paid? |
COACHMET_Y2 |
|
|
| 26. Please indicate how many of your lifestyle coaches are volunteers, hourly contractors, or salaried employees. If none, write "0". |
COACHMET_Y3 |
|
|
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|
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|
|
| If you answer "Other," please specify. |
|
|
| 27. For current grant year, was there any change from previous grant year regarding the funding source in place for lifestyle coach salary? If no, skip to question 30. |
TYPLCREM_Y2 |
|
|
| 28. What is the funding source for lifestyle coaches? Please select ALL that apply. |
TYPLCREM_Y3 |
|
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|
|
| If you answer "Other," please specify. |
|
| 29. What is the average salary of a lifestyle coach, if you are able to report this data? |
LIFESAL |
|
|
|
| 30. What is the funding source for program coordinators? Please select ALL that apply. |
TYPLCOORD_Y3 |
|
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|
|
| If you answer "Other," please specify. |
|
| 31. What is the average salary of a program coordinator, if you are able to report this data? |
COORDSAL |
|
|
|
| 32. What are the credentials of the lifestyle coaches? Please indicate the number of coaches with each of the listed credential using the categories provided. If none, write "0." |
COCHCRED |
|
|
|
|
|
|
|
|
|
|
|
|
|
| If you answer "Other," please specify. |
|
|
| Implementation Strategies |
|
|
|
33. Please select from the list of barriers to program maintenance/sustainability in current grant year. Please select ALL that apply.
|
SITE_BAR |
|
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|
|
|
|
| If you answer "Other," please specify. |
|
| 34. Please select from the list strategies to address barriers listed above at site level. Please select ALL that apply. |
SITESTRAT |
|
|
|
|
|
|
|
|
|
|
| If you answer "Other," please specify. |
|
| Question |
Code |
Response |
| Demographic |
| 1. Site Name (MUST be the Org code that is provided by the DPRP) |
SITE_CODE |
|
|
| 2. Please select from the list the term that best describes your organization. |
SITE_DESC |
|
|
|
If you answer "Other," please specify. |
|
| 3. Please list the full address of your site. |
SITE_LOC |
|
|
| 4. Grant Year |
GRANT_YR |
|
|
| 5. Fiscal Year |
FIS_YR |
|
|
| 6. Year lifestyle change program initiated (i.e., first class conducted) |
CLASSDAT |
|
|
| Intervention Description |
|
|
|
| 7. Please select from the list demographic characteristics of PARTICIPANTS . Please select ALL that apply. |
PAR_CHAR |
|
|
|
|
|
| If you answer "Other," please specify. |
|
| 8. Which DPP curriculum are you using at this site? |
CURRICUL |
|
|
|
|
| 9. Is there purposeful targeting of disparate or vulnerable populations during recruitment for program participation at the site level? If so, what populations are targeted? Please select ALL that apply. |
SVULPOP |
|
|
|
|
|
|
|
|
|
|
|
|
| If you answer "Other," please specify. |
|
| 10. Please select from the list the places from which National DPP participants were recruited. Please select ALL that apply. |
RECRUTPL |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| If you answer "Other," please specify. |
|
| 11. What recruitment methods (i.e., materials or campaigns, from healthcare/insurance company patient rosters, etc.) did you use to identify and recruit new participants? Please select ALL that apply. |
SRECMETH |
|
|
|
|
|
|
|
|
|
|
|
|
| 12. Please select from the list of referral sources to the lifestyle change programs (i.e., clinics, employers/worksites, state health departments, physicians, health centers, private organizations, non-profits, insurers, etc.). Please select ALL that apply. |
OREFLSOR |
|
|
|
|
|
|
|
|
|
| If you answer "Other," please specify. |
|
| 13. Is there any policy in place that establishes a financing/reimbursement mechanism? If so, what entities have implemented the financing/reimbursement mechanism policy? Please select ALL that apply. |
SCOVPOL |
|
|
|
|
|
|
| If you answer "Other," please specify. |
|
| 14. What was the policy that was established? Please select ALL that apply. |
SCOVPOL_Y3 |
|
|
|
|
|
| If you answer "Other," please specify. |
|
| 15. Do you charge participants for the program? If so, and if you are able to report this data, how much do you charge on average per participant? |
PAR_PROGCOST |
|
|
|
| 16. Are there any participation or completion incentives offered to participants? If so, what are the incentive items? Please select ALL that apply. |
SITE_INCENT |
|
|
|
|
|
|
|
|
| If you answer "Other," please specify. |
|
| Resources |
|
|
|
| 17. Please indicate from the list of primary resources necessary for program start-up and implementation (e.g., partnerships/coalition, in-kind contributions, etc.). Please select ALL that apply. |
SITE_RES |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| If you answer "Other," please specify. |
|
|
Location Type |
Number of Classes Offered at this Location |
Location Zip Code |
| 18. In the current grant year, please list the number of and types of locations where classes are offered, and zip codes for all class locations(e.g., employer worksite, community health centers, clinic/practice, community centers, YMCAs, gyms, church, other non-profit, etc.)? Please select ALL that apply. |
PROGPLAC |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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|
|
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|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| If you answer "Other," please specify. |
|
|
|
| 19. Please indicate how many of your lifestyle coaches are volunteers, hourly contractors, or salaried employees. If none, write "0". |
COACHMET_Y3 |
|
|
|
|
|
|
|
| If you answer "Other," please specify. |
|
|
| 20. What is the funding source for lifestyle coaches? Please select ALL that apply. |
TYPLCREM_Y3 |
|
|
|
|
|
|
|
|
|
| If you answer "Other," please specify. |
|
| 21. What is the average salary of a lifestyle coach, if you are able to report this data? |
LIFESAL |
|
|
|
| 22. What is the funding source for program coordinators? Please select ALL that apply. |
TYPLCOORD_Y3 |
|
|
|
|
|
|
|
|
|
| If you answer "Other," please specify. |
|
| 23. What is the average salary of a program coordinator, if you are able to report this data? |
COORDSAL |
|
|
|
| 24. What are the credentials of the lifestyle coaches? Please indicate the number of coaches with each of the listed credential using the categories provided. If none, write "0." |
COCHCRED |
|
|
|
|
|
|
|
|
|
|
|
|
|
| If you answer "Other," please specify. |
|
|
| Implementation Strategies |
|
|
|
25. Please select from the list the barriers to program start-up and implementation. Please select ALL that apply.
|
SITE_BAR |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| If you answer "Other," please specify. |
|
| 26. Please select from the list strategies to address barriers listed above at site level. Please select ALL that apply. |
SITESTRAT |
|
|
|
|
|
|
|
|
|
|
| If you answer "Other," please specify. |
|
| SITE_DESC |
SITE_LOC |
SITE_FOCY2 |
SITE_FOCY3 |
CURRICUL_Y2 |
CURRICUL_Y3 |
PAR_NEW |
PAR_CHAR |
SVULPOP |
SITE_ADAPT |
RECRUTPL |
SRECMETH |
SCOVPOL_Y2 |
SCOVPOL_Y3 |
SITE_INCENT |
SITE_RES |
PROGPLAC |
OREFLSOR |
COACHMET_Y3 |
TYPLCREM_Y3 |
TYPLCOORD_Y3 |
COCHCRED |
SITE_BAR |
SITESTRAT |
PAR_PROGCOST |
COORDSAL |
| YMCA |
AL |
Yes, all |
Employer worksite |
Yes |
CDC's National DPP |
Yes |
Rural |
No targeting of NEW disparate or vulnerable populations |
Have not adapted the lifestyle change program |
Did not recruit from any NEW places |
Did not engage in any participant recruitment |
No change in policy |
Employee coverage benefit |
No incentives for participation or completion were offered |
Grant funding |
Employer worksite |
No NEW referral sources |
Volunteer |
No additional funding needed: volunteer |
No additional funding needed: volunteer |
Certified Diabetes Educator (may also be counted in a category below) |
Site’s organizational capacity to implement National DPP |
Improve communication/engagement with partners/key stakeholders |
No, do not charge for participant fee |
They are volunteers with no salary incurred from our organization |
| Universities/schools |
AK |
No, none |
Faith-based org |
No |
Y-DPP (Plan Forward) |
No |
Urban |
Low SES |
Delivery bilingual or using non-English language |
Hospitals or healthcare systems (including hospital owned practices) |
Distributing or displaying paper marketing materials (i.e. flyers, pamphlets, brochures, and/or posters) |
Insurance |
Insurance coverage benefit |
Pedometers |
Partnerships/coalitions |
Faith-based org |
Hospitals or healthcare systems Healthcare clinics/centers/groups (including affiliated physician practices) |
Hourly Contractor |
No additional funding needed: site-level staff responsibility added without pay increase |
No additional funding needed: site-level staff responsibility added without pay increase |
Licensed nutritionist or dietician |
Procuring funding and/or program reimbursement |
Offering additional classes |
Yes, and able to report |
They are salaried staff and we are able to report their salary; please report |
| Local health departments |
AZ |
Some |
Community center |
N/A |
Group Lifestyle Balance (U Pitt) |
N/A |
Low-income |
Under or uninsured |
Use of cultural themes, images, or sayings |
Physician practices not affiliated with a healthcare system |
Direct recruitment by program staff (i.e. approaching participants one-on-one in their physician office or other setting) |
Employer |
Pay for performance |
Digital physical activity trackers |
In-kind contributions |
Community center |
Physician practices not affiliated with a healthcare system |
Salaried |
Insurance reimbursement |
Insurance reimbursement |
Pharmacist |
Staff support |
Expanding marketing efforts to community to increase participant enrollment |
Yes, but not able to report |
They are salaried staff, but we are not able to report their salary |
| Hospitals/healthcare systems/medical groups/physician practices |
AR |
N/A |
Government building |
|
Native Lifestyle Balance |
|
Under or Uninsured |
Race/ethnicity: African-American |
Addressing traditionally male or female roles |
Federally Qualified Health Center (FQHC) |
Conducting or participating in health fairs and/or other community outreach activities (including blood glucose screening events at worksites) |
National |
Participant fee waiver or scholarship paid by grant |
Gym memberships |
Volunteer staff, |
Government building (non-community center) |
Federally Qualified Health Centers (FQHC) |
Other |
Grant funding (CDC) |
Grant funding (CDC) |
Registered nurse |
Staff turnover |
Offer financial assistance to help participants pay for the program through grant/3rd party payers |
N/A |
N/A |
| Community-based orgs/community health centers/FQHCs |
CA |
|
Physician office |
|
New Prevent T2 Curriculum |
|
Other |
Race/ethnicity: Hispanic/Latino |
Incorporating cultural dietary restrictions or preferences |
Native American clinic/IHS clinic |
Recruiting providers to make referrals during patient visit or to send letters/postcards to patients |
Other |
New in kind support |
Physical activity videos or CDs |
Access to organization member base |
Small business worksite where participants not employed (i.e., car dealership, grocery store, etc.) |
Employers/worksites |
|
Grant funding (other governmental) |
Grant funding (other governmental) |
Physician |
Lack of clear program guidance |
Seeking in-kind classroom space |
|
|
| Pharmacy sites |
CO |
|
Healthcare center/practice |
|
Help Prevent Diabetes (Wake Forest) |
|
N/A |
Race/ethnicity: Native American |
Other |
Employers/worksites (incl. employer wellness programs) |
Recruiting other organizational partners to make direct referrals or recruit via contact lists |
|
Employer sponsored delivery |
Athletic gear or clothing |
Providers/participants incentives |
Healthcare or medical center/practice/clinic (non-hospital) |
State or local health departments |
|
Grant funding (other nongovernmental) |
Grant funding (other nongovernmental) |
Health educator |
Buy-in/communication with partners |
Pilot an e-referral system from healthcare providers |
|
|
| Indian Health Services/Native American/Tribal Health Systems |
CT |
|
Y-facilities |
|
N/A |
|
|
Race/ethnicity: Asian/Pacific Islander |
|
State or local health departments |
Advertising and press release in newsletters, local newspapers, radio, or television stations |
|
Other |
Calorie King or other type of diet tracking books |
Office space, equipment, supplies |
Hospital or bldg. on hospital campus |
Other government entity |
|
Participant fees (pay part of lifestyle coaching salary) |
Participant fees (pay part of lifestyle coaching salary) |
Exercise specialist |
Space for program delivery |
Provide additional benefits to participants to access other programs at their facilities |
|
|
| Business coalition/coop-extension sites |
DE |
|
Health plan retail centers |
|
|
|
|
Race/ethnicity: other (describe) |
|
Other government entity |
Social media postings (i.e., FB, Twitter, Instagram) |
|
N/A |
MyPlates or other food measuring devices |
Human resource capital |
University hospital bldg. |
Faith-based orgs |
|
In-Kind from partner organization |
In-kind from partner organization |
Community Health Worker |
Healthcare providers or physician resistance to refer to program |
Other |
|
|
| Worksite/employee wellness programs |
FL |
|
Cooperative Extensions |
|
|
|
|
Geography: rural or frontier |
|
Community center (i.e., library, Ruritan/Lions club, Centers on Aging, etc.) |
Presentations/information sessions to community/employees |
|
|
Cookbooks |
Educational sessions to potential key stakeholders |
YMCA |
Other non-profit org |
|
Other |
Other |
Other |
Low enrollment/recruitment |
N/A |
|
|
| Senior/aging/elderly centers |
GA |
|
Federally qualified health centers |
|
|
|
|
Geography: urban |
|
YMCA |
Volunteer recruiters from previous lifestyle change classes (through word-of-mouth, phone, or email) |
|
|
Discount coupons |
Scale for weight measurement, privacy screen |
Fitness centers/gyms |
Self-referral via org website/online participant portal |
|
N/A |
N/A |
N/A |
Participant drop-out |
|
|
|
| Faith-based orgs |
HI |
|
Gyms/Recreation centers |
|
|
|
|
Elderly |
|
Fitness centers/gyms |
Posting on Organization website, or email blast to members |
|
|
Gift cards |
Location to hold classes |
University center/classroom |
Other |
|
|
|
|
Class schedule timing |
|
|
|
| Health plans/insurers/ managed care org |
ID |
|
Other |
|
|
|
|
Disabled |
|
Other |
|
|
|
Program access incentives such as bus pass or parking pass |
Travel budget to site location |
Tribal clinic/center |
N/A |
|
|
|
|
Fee charged to participants |
|
|
|
| Other |
IL |
|
N/A |
|
|
|
|
Other (describe) |
|
N/A |
|
|
|
Free or reduced child care |
Relationship with business groups (Chamber of Commerce, Brokers, Business Coalitions on health) |
Cooperative Extension |
|
|
|
|
|
Competing priorities with organization's other diabetes control program for referral |
|
|
|
|
IN |
|
|
|
|
|
|
N/A |
|
|
|
|
|
Healthful food snacks or samples |
Marketing materials |
Other |
|
|
|
|
|
Competing program with other partners that also offer lifestyle change program at their facilities |
|
|
|
|
IA |
|
|
|
|
|
|
|
|
|
|
|
|
Certificates or plaque/trophy |
Other |
N/A |
|
|
|
|
|
Lack of alignment of the program with site mission and values |
|
|
|
|
KS |
|
|
|
|
|
|
|
|
|
|
|
|
Cash prizes |
N/A |
|
|
|
|
|
|
Perceived difficulty of implementing the program |
|
|
|
|
KY |
|
|
|
|
|
|
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|
|
|
|
Commitment contracts |
|
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|
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|
|
Other |
|
|
|
|
LA |
|
|
|
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|
|
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|
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|
|
Other |
|
|
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|
|
N/A |
|
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|
ME |
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MD |
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MA |
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MI |
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MN |
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MO |
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MT |
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NE |
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NV |
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NH |
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NJ |
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NM |
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NY |
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NC |
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ND |
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OH |
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OK |
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OR |
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PA |
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RI |
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SC |
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SD |
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TN |
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TX |
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UT |
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VT |
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VA |
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WA |
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WV |
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WI |
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| SVULPOP |
RECRUTPL |
SRECMETH |
SCOVPOL |
SCOVPOL_Y3 |
OFELSOR |
| No targeting of disparate or vulnerable populations |
Hospitals or healthcare systems (including hospital owned practices) |
Did not engage in any participant recruitment |
N/A |
Employee coverage benefit |
Hospitals or healthcare systems Healthcare clinics/centers/groups (including affiliated physician practices) |
| Low SES |
Physician practices not affiliated with a healthcare system |
Distributing or displaying paper marketing materials (i.e. flyers, pamphlets, brochures, and/or posters) |
Insurance |
Insurance coverage benefit |
Physician practices not affiliated with a healthcare system |
| Under or uninsured |
Federally Qualified Health Center (FQHC) |
Direct recruitment by program staff (i.e. approaching participants one-on-one in their physician office or other setting) |
Employer |
Pay for performance |
Federally Qualified Health Centers (FQHC) |
| Race/ethnicity: African-American |
Native American clinic/IHS clinic |
Conducting or participating in health fairs and/or other community outreach activities (including blood glucose screening events at worksites) |
National |
Participant fee waiver or scholarship paid by grant |
Employers/worksites |
| Race/ethnicity: Hispanic/Latino |
Employers/worksites (incl. employer wellness programs) |
Recruiting providers to make referrals during patient visit or to send letters/postcards to patients |
Other |
In kind support |
State or local health departments |
| Race/ethnicity: Native American |
State or local health departments |
Recruiting other organizational partners to make direct referrals or recruit via contact lists |
|
Employer sponsored delivery |
Other government entity |
| Race/ethnicity: Asian/Pacific Islander |
Other government entity |
Advertising and press release in newsletters, local newspapers, radio, or television stations |
|
Other |
Faith-based orgs |
| Race/ethnicity: Other (describe) |
Community center (i.e., library, Ruritan/Lions club, Centers on Aging, etc.) |
Social media postings (i.e., FB, Twitter, Instagram) |
|
N/A |
Other non-profit org |
| Geography: Rural or frontier |
YMCA |
Presentations/information sessions to community/employees |
|
|
Self-referral via org website/online participant portal |
| Geography: Urban |
Fitness centers/gyms |
Volunteer recruiters from previous lifestyle change classes (through word-of-mouth, phone, or email) |
|
|
Other |
| Elderly |
Other |
Posting on Organization website, or email blast to members |
|
|
N/A |
| Disabled |
N/A |
|
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|
|
| Other (describe) |
|
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|
|
| N/A |
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