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pdfDRAFT FORM
OMB No.
Exp. Date:
N
W
E
Office Use PID: _______________________________ Inc/Prev. Year_______________________________
SEARCH
For Diabetes in Youth
* Note: Fonts are Times New Roman & Smudger LET Plain.
Initial Participant Survey
Adult Version
This survey is to be filled out by the person
(18 years or older) who has diabetes.
Your answers will be kept confidential and
will be used for study purposes only.
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)
Privacy Act Statement
The information you are being asked to provide is authorized to be
collected under Section 301 of The Public Health Service Act (42 USC
241). Providing this information is voluntary. CDC will use this
information in its study, SEARCH for Diabetes in Youth, in order to: (1)
Assess the incidence and prevalence of diabetes among youth in the U.S.
by diabetes type, and by demographics including age, sex, and race/
ethnicity; and (2) Assess temporal trends in diabetes incidence in major
US racial/ethnic groups, including African Americans, Hispanics, American
Indian Tribes, Asian Americans, Pacific Islanders, by age, sex, and
diabetes type. This information will be shared with third party clinical
entities with whom CDC has entered into an Agreement to assist with
carrying out this Study.
SEARCH Registry Study — Prevalent Initial Participant Survey (Adult Verison) revised 3-22-16
SEARCH for Diabetes in Youth
We want to learn more about children and adults who have
diabetes, and how diabetes affects their lives. You can help us
learn more by answering the following questions. You may ask
your Parent or another adult to help you.
1. What is TODAY’S date?
______ /______ /___________
Month
Day
Year
For example, if today is May 1, 2016, write in 05/01/2016
2.
What is your sex?
1q
Female
3. What is your BIRTHDATE?
2q
Male
______ /______ /___________
Month
Day
Year
4.
Has a doctor or nurse ever told you that you have diabetes?
1q
YES. Please go to the next page.
2q
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
5.
N
When did a doctor or nurse first tell you that you had diabetes?
This means when you were told about your diabetes diagnosis.
______ /______ /___________
Month
Day
Year
W
6.
Please list all the places you lived during the year you were diagnosed with diabetes.
For example if you were diagnosed in April 2016, list everywhere you lived from
January 2016 through December 2016.
_______________________________________________________________________
City
State
Zip Code
County
_______________________________________________________________________
City
State
Zip Code
County
_______________________________________________________________________
City
State
Zip Code
County
We are going to ask you some questions about when you first got diabetes, and how
your diabetes is treated. Please answer the questions as best as you can. If you do
not know the answer to a question, leave it blank.
7.
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
S
I found out that I had diabetes because I was thirsty, had to pee a lot,
or got sick very quickly.
I found out that I had diabetes at a yearly physical or check-up with
my regular doctor.
I found out that I had diabetes when my blood sugar was checked at a
health fair or by a school nurse.
I found out that I had diabetes when I was pregnant and the diabetes
did not go away after the pregnancy.
If none of the above apply to you, please write on the lines below how you first found out you had diabetes.
________________________________________________________________________________________
________________________________________________________________________________________
* Note: Fonts are Times New Rom
________________________________________________________________________________________
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SEARCH for Diabetes in Youth
N
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?
9.
E
1q
Yes
1q
2q
Yes
No
2q
1q
Yes
2q
No
No
If Yes, what was the medicine?______________________________________________
Since being diagnosed with diabetes, have you ever taken insulin?
1q
Yes
2q
No (If No, skip to question 10)
9a. Were you taking insulin two weeks after diagnosis?
9b. Are you taking insulin now?
1q
Yes
2q
SEARCH
For Diabetes in Youth
1q
Yes
2q
No
No
10. How else do you take care of your diabetes now?
Do you: (please check Yes or No for each question)
10a. Take prescribed tablets (pills) for diabetes?
10b. Follow a diet/meal plan (for example, carbohydrate counting)?
10c. Follow an exercise program?
10d. Any treatments other than insulin, pills, diet, or exercise: (If yes, please list below.)
________________________________________________________________________
________________________________________________________________________
1q
Yes
2q
1q
Yes
2q
No
1q
Yes
2q
No
No
11. Who do you usually see for most of your care related to diabetes?
(Please check only one response).
1.
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 provider (nurse, nurse practitioner, physician assistant,
certified diabetes educator, or other)
7. q Unsure
man & Smudger LET Plain.
8. q No current health care provider
SEARCH for Diabetes in Youth
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Now we would like to ask about your health insurance.
12. What kind of health insurance plan did you have when you were DIAGNOSED with diabetes?
And what kind of health insurance plan do you have NOW?
(Please answer Yes or No for each question for insurance at time of DIAGNOSIS and NOW.)
HEALTH INSURANCE TYPE
Health Insurance at
TIME OF DIAGNOSIS
Health Insurance
NOW
YES
NO
YES
NO
12a. Medicaid/Medicare
1q
2q
1q
2q
12b. Private insurance, through employer
1q
2q
1q
2q
12c. Private insurance, purchased on your own
1q
2q
1q
2q
12d. Private insurance, purchased through the health
insurance exchange or marketplace
1q
2q
1q
2q
12e. Military
1q
2q
1q
2q
12f. School or college-based insurance
1q
2q
1q
2q
12g. Tribe/Indian Health Service
1q
2q
1q
2q
12h. Any other or type unknown
1q
2q
1q
2q
12i. No health insurance
1q
2q
1q
2q
13. Are you Spanish/Hispanic/Latino? (Mark X in the “No” box if not Spanish/Hispanic/Latino)
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q No, not Spanish/Hispanic/Latino
q Yes, Puerto Rican
q Yes, Mexican, Mexican American, Chicano
q Yes, Cuban
q Yes, other Spanish/Hispanic/Latino – Print group in the space below:
__________________________________________________________
SEARCH for Diabetes in Youth
14. 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 below:
____________________________________________________________________
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:_______________________________________
15. What is the highest degree or level of school that you, your Parent/Guardian #1 and
Parent/Guardian #2 have completed?
Yourself
Parent /
Guardian #1
Parent /
Guardian #2
15a. Any education less than a high school
graduate, no diploma or GED
1q
1q
1q
15b. High school graduate, (high school
diploma) or equivalent (for example, GED)
2q
2q
2q
15c. Business/technical school, associate
degree (AA, AS) or some college
3q
3q
3q
15d. Bachelor degree (for example, BA, AB,
BS) (4-year)
4q
4q
4q
15e. Master degree (for example MA, MS,
MEng, Med., MSW)
5q
5q
5q
15f. Professional or doctorate degree (for
example, MD, DDS, JD, PhD, EdD)
6q
6q
6q
15g. Don’t know
7q
7q
7q
SEARCH for Diabetes in Youth
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16. Which of these categories best describes the total income of all persons living in your household
for the past 12 months? (Income could be from salary, social security, retirement, Medicaid,
disability, alimony, child support, etc.)
Check only one category:
1. q Less than $5,000
6.
q $35,000 through $49,999
7. q $50,000 through $74,999
8. q $75,000 through $99,999
9. q $100,000 and greater
10. q Don’t know
2. q $5,000 through $11,999
3. q $12,000 through $15,999
4. q $16,000 through $24,999
5. q $25,000 through $34,999
17. How many people are currently living in your household, including yourself?
17a. Total number of people ______
17b. Number of children (less than 18 years)_____
17c. Number of adults_____
17d. Please mark which adults live in the household
YES
NO
Mother
q
q
Father
q
q
Guardian
q
q
Roommate/ Friend
q
q
Spouse/Partner
q
q
Other adult(s)
q
q
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.
18. Does your biological mother have diabetes?
18a.
1q
Yes
2q
No
3q
Don’t know
q If Yes, how old was she when she was diagnosed with diabetes?
_______ years q Don’t know
19. 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.
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1q
Yes
2q
No
3q
Don’t know
20. Does your biological father have diabetes?
1q
Yes
2q
No
3q
Don’t know
20a. q If Yes, how old was he when he was diagnosed with diabetes?
_______ years
q Don’t know
21. Do you have any full or half brothers?
1q
(If No or Don’t know, skip to question 22)
2q
No
3q
Don’t know
21a. If Yes, how many full or half brothers do you have?
Yes
_______ brothers
21b. If Yes, how many full or half brothers have diabetes?
_______ brothers
22. Do you have any full or half sisters?
1q
(If No or Don’t know, skip to question 23)
2q
No
3q
Don’t know
22a. If Yes, how many full or half sisters do you have?
Yes
_______ sisters
22b. If Yes, how many full or half sisters have diabetes?
_______ sisters
23. Were you born in the United States?
1q
Yes (If Yes, go to question 24)
2q
No
23a. If no, in what country were you born? Write in country of birth.
23b. In what year did you come to the United States to live? Write in year. _______________
3q
Don’t know; prefer not to say
SEARCH for Diabetes in Youth
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24. Was your mother born in the United States?
1q
Yes
2q
No
(If Yes, go to question 25)
24a. If no, in what country was your mother born? Write in country of birth.
q Don’t know country
24b. In what year did your mother come to the United States?
q Don’t know year
q Did not come to the United States
3q
Write in year.
Don’t know; prefer not to say
25. Was your father born in the United States?
1q
Yes (If Yes, go to next page)
2q
No
25a. If no, in what country was your father born? Write in country of birth.
q Don’t know country
25b. In what year did your father come to the United States?
q Don’t know year
q Did not come to the United States
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3q
Don’t know; prefer not to say
Write in year.
26. During the year 2017, list all the places where you lived.
CITY
STATE
ZIP CODE
COUNTY
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
27. On April 1st 2017, were you in the Army, Navy, Air Force, Marines, or the Coast Guard?
1 Yes 2 No 3 Don’t know
28. When you first got diabetes, were you in the Army, Navy, Air Force, Marines, or the Coast Guard?
1 Yes 2 No 3 Don’t know
Contact Information
We would like to be able to reach you in the future to provide information about the SEARCH study.
Please provide the best contact information below.
A.
What is your name?
First Name
Middle Name
Last Name
Are there any other names that you use?
Other first names
Other last names
B.
Full Name of Parent or Guardian #1 of child (Please note if Parent or Guardian.)
First Name
Middle Name
Last Name
q Parent q Guardian #1
C.
“Full Name of Parent or Guardian #2 of child (Please note if Parent or Guardian.)
First Name
Middle Name
Last Name
q Parent q Guardian #2
SEARCH for Diabetes in Youth
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D.
Provide your current address, email and phone number for future contact.
P.O. Box
City
State
Email address
Street
Apt#
Zip Code
Phone number (best)
area code
Is this:
q Home q Work q Cellular Phone q Other
Phone number (other)
area code
Is this:
q Home q Work q Cellular Phone q Other
Phone number (other)
area code
Is this:
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q Home q Work q Cellular Phone q Other
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/or email addresses of a relative or friend, someone who would know
how to 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
Street
Apt#
Zip Code
Phone number (best)
area code
extension
area code
extension
area code
extension
Phone number (other)
Phone number (other)
SEARCH for Diabetes in Youth
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Contact #2:
First Name
Middle Name
Last Name
Relationship
P.O. Box
City
State
Email address
Street
Apt#
Zip Code
Phone number (best)
area code
extension
area code
extension
area code
extension
Phone number (other)
Phone number (other)
Thank You for filling out this survey.
Please mail it to us in the stamped, pre-addressed envelope.
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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
N
W
E
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 | 2017-10-13 |
| File Created | 2016-09-19 |