Post-Session Survey

Place ID label here

POST-SESSION SURVEY

Now that you have finished the Information Session, please take a few minutes to answer the following questions before you leave. 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 10 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 lifestyle change program.

1. On a scale of 1 to 5, 1 being very unlikely and 5 being very likely, please indicate your response 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

2. In the table below, please fill in the circle under the column that best matches how strongly you agree or disagree 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.					

3. 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 (please explain why in the box below)

I do not plan to sign up for the lifestyle change program (please explain why in the box below)

Below, please give a short explanation why you are not sure about signing up or do not intend to sign up for the lifestyle change program. You may stop the survey and skip questions 4-7.

4. How important was today’s Information Session to your plan to sign up for the lifestyle change program (now or in the future)? On a scale of 1 to 5, 1 being not at all important and 5 being extremely important, please indicate your response by circling a number below.

1	2		3		4		5
Not at all important						Extremely important

5. 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 healthcare 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.
What I learned during the Information Session about type 2 diabetes.
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):

6. Thinking about the reasons for which you selected “yes” above, which had the biggest effect on your plan to sign up for the lifestyle change program? Write the letter associated with the reason on the line below (for example, write “a” for a friend or family member).

__________

7. How would you like to get reminders about the first session of the lifestyle change program? Please choose either text, phone, or e-mail by checking the appropriate box below. Check all that apply.

• Text

• Phone

• E-mail

• No, thank you. I do not wish to be contacted.

Thank you! Please give this survey to a staff member before you leave.

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.