Form 0920-0572 PWD Screener Online Survey

OMB No. 0920-0572

Expiration Date 08/31/2021

Brand Concept Testing
for Diabetes Self-Management Education and Support (DSMES) Services: Screener for People with Diabetes

Introduction

This effort is sponsored by the U.S. Centers for Disease Control and Prevention, also known as CDC. If you qualify for the survey and participate, you will receive a $10 gift card as a thank you for participating.

The following questions will determine your eligibility to participate in the survey and will include topics like your age, health, and ethnicity. You do not have to answer anything that makes you uncomfortable.

Screening Questions

1. What is your gender

• Male Continue

• Female Continue

2. What is your age?

• Under 18 TERMINATE

• 18-44 Continue

• 45-64 Continue

• 65 or over Continue

3. Have you been diagnosed with diabetes by a health care provider?

• Yes Continue

• No TERMINATE

• 

  Public Reporting Statement

  Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the 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/ATSDR Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0572). 

  Do not know/Unsure TERMINATE

4. What type of diabetes have you been diagnosed with, Type 1 or Type 2, or some other type (such as gestational or cancer-related)?

• Type 1 Continue

• Type 2 Continue

• Gestational TERMINATE

• Other type of diabetes TERMINATE

• Do not know/Unsure TERMINATE

5. Do you, or does any member of your household or immediate family, work as a health care professional (diabetes educator, doctor, nurse, pharmacist, dietician, community health worker, etc.)?

• Yes TERMINATE

• No Continue

6. Do you, or does any member of your household or immediate family, work in a medical office, hospital, health care system, or pharmaceutical company?

• Yes TERMINATE

• No Continue

7. Has a health care provider ever referred you to diabetes education? I am specifically referring to diabetes education where you meet with a diabetes care and education specialist in either one-on-one, in a group or online. These services help people keep on track to live well with diabetes. Diabetes care and education specialists connect people with resources to build skills, knowledge and tools to reach their goals. Sessions can be on eating healthy, checking blood sugar, being active, managing stress, and problem solving.

• Yes CONTINUE

• No CONTINUE

• Do not know/Unsure TERMINATE

8. Have you ever participated in diabetes education to which your health care provider referred you? Again, I am specifically referring to one where you meet with a diabetes care and education specialist either in a group, one-on-one or online.

• Yes SPECIFY NAME OF PROGRAM _____________

• No CONTINUE

• Do not know/Unsure CONTINUE

9. Did you participate in the diabetes education within the last 24 months?

• Yes CONTINUE

• No CONTINUE

• Do not know/Unsure CONTINUE

10. [IF YES to Q9] Thinking specifically about the diabetes education you participated in approximately how many hours of diabetes education have you received through this program?

• RECORD NUMBER OF HOURS _____________ CONTINUE

(ALLOW DON’T KNOW, NOT SURE) (RECORD NONE AS 0)

11. How long have you had diabetes?

• Less than 2 years Continue

• 2-9 years Continue

• 10 or more years Continue

12. Have you ever experienced any health problems as a result of having diabetes? For example, these may include eye problems, foot or nerve pain, kidney problems, amputations, or heart problems.

• Yes CONTINUE

• No CONTINUE

13. How much do you agree or disagree with the following statement: I believe it is important to get regular medical check-ups.

• Strongly Disagree Continue

• Somewhat Disagree Continue

• Neither agree nor disagree Continue

• Somewhat Agree Continue

• Strongly Agree Continue

14. Which of the following best describe the area where you live?

• Urban Continue

• Suburban Continue

• Rural Continue

15. What is the highest level of education you have completed?

• Less than high school graduate Continue

• High school graduate or completed GED Continue

• Some college or technical school Continue

• A four-year college degree Continue

• Higher than a 4-year college degree (e.g., Master’s degree, PhD) Continue

• Other (specify): _____________________ TERMINATE

16. Please tell me your race or ethnic background in the next 2 questions. How do you describe your ethnicity?

• Hispanic or Latino Continue

• Not Hispanic or Latino Continue

17. How do you describe your race? [select all that apply]

• American Indian or Alaska Native Continue

• Asian Continue

• Black or African American Continue

• Native Hawaiian or Other Pacific Islander Continue

• White Continue

TERMINATION LANGUAGE

Thank you very much for your time. You do not qualify for the study, so we won’t be able to include you this time. Thank you for your time and interest. Have a good day.

INVITATION FOR SURVEYS:

[ROUTE TO INFORMED CONSENT]

Screener People with Diabetes for DSMES Brand and Message Concept Testing 5