Initial Participant Survey - Incident Case Young Adult V

SEARCH for Diabetes in Youth

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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.
CIiek here to begin the participant survey

This survey is to be filled out by a Parent or
legal Guardian of the child age less than 18
years old 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)
OMB.

 PROFILE MANAGER: JULIA ROBERTSON 

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   Young Adult

Re­enter Participant Identification:

Verify participant ID

We want to learn more about children and adults who have diabetes,
and how diabetes a爀漀ects 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? For example, if today is May 1, 2016, write in 05/01/2016.

2.

What is your sex?

What is your BIRTHDATE Month?

3.

4.

What is your BIRTHDATE Year?

Has a doctor or nurse ever told you that you have diabetes?

5.
When did a doctor or nurse first tell you that you had diabetes? This means when you were told
about your diabetes diagnosis. (Month)

When did a doctor or nurse first tell you that you had diabetes? This means when you were told
about your diabetes diagnosis. (Year)

6.
Please list all the places you lived during the year you were diagnosed with diabetes. For example,
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 㜀㌀rst got diabetes, and how your
diabetes is treated. Please answer the questions as best 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)

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 check­up 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.

Has a doctor or nurse ever told you that your diabetes was caused by:
8.

8a.

(please check Yes or No for each question)

Cystic fibrosis?

Cancer or medicine to treat cancer?

Another medicine?

8b.

8c.

9.

If Yes, what was the medicine?

Since being diagnosed with diabetes, have you ever taken insulin?

9a.

Were you taking insulin two weeks after diagnosis?

Are you taking insulin now?

9b.

How else do you take care of your diabetes now?
10.
10a.

Do you: (please check Yes or No for each question)

Take prescribed tablets (pills) for diabetes?

Follow a diet/meal plan (for example, carbohydrate counting)?

Follow an exercise program?

Any treatments other than insulin, pills, diet, or exercise: (if yes, please list below.)

10b.

10c.

10d.

Who do you usually see for most of your care related to diabetes?
11.

(Please check only one response).

Now we would like to ask about your health insurance.
What kind of health insurance did you have when you were DIAGNOSED with diabetes?
And what kind of health insurance do you have NOW?
12.

(Please answer Yes or No for each question for insurance at time of DIAGNOSIS and NOW)

Health Insurance at TIME OF DIAGNOSIS

12a

Medicaid/Medicare

12b.

Private insurance, through employer

Private insurance, purchased on your own

Private insurance, purchased through the health insurance exchange or marketplace

Military

School or college­based insurance

12c.

12d.

12e.

12f.

12g.

Tribe/Indian Health Service

Any other or type unknown

12h.

12i.

No health insurance

Health Insurance NOW

12j.

Medicaid/Medicare

Private insurance, through employer

Private insurance, purchased on your own

12k.

12l.

12m.

Private insurance, purchased through the health insurance exchange or marketplace

12n.

Military

School pr college­based insurance

Tribe/Indian Health Service

Any other or type unknown

12o.

12p.

12q.

12r.

No health insurance

13.

Are you Spanish/Hispanic/Latino?

Other Spanish/Hispanic/Latino:

14.

What is your race? Mark one or more races to indicate what you consider yourself to be.

 White

 Black, African American

 American Indian or Alaska Native; Print name of enrolled or principal tribe below:

 Asian Indian

 Japanese

 Native Hawaiian

 Chinese

 Korean

 Guamanian or Chamorro

 Filipino

 Vietnamese

 Samoan

 Other Asian; Print race:

 Other Pacific Islander; Print race:

 Race Known Missing
15.
What is the highest degree or level of school that you, your Parent/Guardian #1 and
Parent/Guardian #2 have completed?
15a.

Yourself

Parent/Guardian #1

Parent/Guardian #2

15b.

15c.

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:

17.

How many people are currently living in your household, including yourself?

17a.

Total number of people

17b.

Number of children (less than 18)

17c.

Number of adults

17d.

Please mark which adults live in the household

Mother

Father

Guardian

Roommate/Friend

Spouse/Partner

Other adult(s)

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.

If Yes, how old was she when she was diagnosed with diabetes?

 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.

20.

Does your biological father have diabetes?

20a.

If Yes, how old was he when he was diagnosed with diabetes?

 Don't know
21.

Do you have any full or half brothers?

21a.

If Yes, how many full or half brothers do you have?

21b.

If Yes, how many of your full or half brothers have diabetes?

22.

Do you have any full or half sisters?

22a.

If Yes, how many full or half sisters do you have?

22b.

If Yes, how many of your full or half sisters have diabetes?

23.

Were you born in the United States?

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.

24.

Was your mother born in the United States?

24a.

If no, in what country was your mother born? Write in country of birth.

 Don't know country
24b.

In what year did your mother come to the United States? Write in year.

 Don't know year
 Did not come to the United States
25.

Was your father born in the United States?

25a.

If no, in what country was your father born? Write in country of birth.

 Don't know country
25b.

In what year did your father come to the United States? Write in year.

 Don't know year
 Did not come to the United States

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