Pre-Session Survey

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PRE-SESSION SURVEY

Before the Information Session begins, please take a few minutes to answer the following questions. The information that you share will help our team better understand some of the reasons why people, like you, decide to do programs for preventing or delaying type 2 diabetes and improving their overall health. This survey should take no more than 5 minutes to complete.

Completing this survey is voluntary (you don’t have to do it). You can choose not to answer any questions or stop filling out the survey at any time without any penalty.  Your decision to complete this survey will not affect your ability to attend the Information Session or the lifestyle change program.

Date:
First Name:
Last Name:
Phone number (Home):
Phone number (Cell):
E-mail:

We’re glad to have you! Please tell us a little more about yourself by answering the questions below.

How did you hear about us? (check all that apply)

Referral from friend or family

Did this person attend the lifestyle change program, or are they currently enrolled in the lifestyle change program? □ Yes □ No

Referral from a doctor or other health care provider

Program material (handout, pamphlet)

Other, please specify: ____________________________________________________________

Have you ever been enrolled in the lifestyle change program? (check answer) □ Yes □ No

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PRE-SESSION SURVEY

Before we start the session, please also answer the following questions.

1. Have you been told by a health care provider that you have type 2 diabetes? (check answer below)

□ Yes □ No

2. Have you been told by a health care provider that you are at risk of developing type 2 diabetes? (check answer below)

□ Yes □ No

3. On a scale of 1 to 5, 1 being very unlikely and 5 being very likely, please indicate your answer by circling a number below.

How likely do you think you are to develop type 2 diabetes in your lifetime?

1	2		3		4		5
Very unlikely						Very likely

4. In the table below, please fill in the circle under the column that best matches how strongly you disagree or agree with each statement.

STATEMENT	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
It will be easy for me to change my lifestyle in order to prevent or delay my chances of developing type 2 diabetes.					
I see myself as someone who would benefit from doing the lifestyle change program to prevent or delay my chances of developing type 2 diabetes.					
I am sure that I can do the lifestyle change program, even if it requires me to attend weekly classes.					
I feel comfortable being here with other people who are interested in preventing or delaying their chances of developing type 2 diabetes.					
Deciding to do the lifestyle change program is worth the time because I will be healthier in the future.					
I think that doing the lifestyle change program as soon as possible is important to prevent or delay my chances of developing type 2 diabetes.					

5. Please read the following statement and check one of the choices below.

I plan to sign up for the lifestyle change program to prevent or delay my chances of developing type 2 diabetes:

Today

Next week

Next month

Next year

I am not sure (skip to question 7)

I do not plan to sign up for the lifestyle change program (skip to question 7)

6. What are the main reasons why you plan to sign up for the lifestyle change program? Please place an “X” next to any statement that applies to you.

Reasons for signing up for the lifestyle change program	Place an “X” below if yes
A friend or family member encouraged me or asked me to do it.
My doctor (or other health care provider) referred me and/or recommended the program.
I like the idea of participating in a program with other people with the same goals.
I like the idea of participating in a structured program.
I want to lose weight.
I want to learn how to eat better.
I’ve been looking for an exercise and nutrition program, and this one seems good.
Other (please explain):

7. With which of these do you identify? (check all that apply)

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific Islander

White or Caucasian

Other, please specify ________

8. Are you also Hispanic or Latino? (check answer)

Yes

No

I don’t know

9. What type of insurance do you have? (check all that apply)

I do not have insurance

Medicaid

Medicare

Private insurance

Military health care

Other, please specify ________

10. What is your gender? (check answer)

Male

Female

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11. What is your age? (check answer)

18-34

35-44

45-54

55-64

65-74

75+

If you have questions or concerns, please contact Tara Earl, Project Manager, toll-free at 1-844-835-2250 and/or [email protected]]. For questions about the rights of participants, call the Abt Institutional Review Board toll-free at 877-520-6835.

Thanks for this information! Please return this survey to a staff member when you are finished.