Form 0920-0572 Screener Diabetes Educators

OMB No. 0920-0572

Expiration Date 3/31/2021

MESSAGE TESTING CARD SORT SCREENER FOR DIABETES EDUCATORS

October 7, 2019

To be included on the first page: 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). 

Diabetes Educators (DE) Screener

To recruit DEs, we are assuming that the American Diabetes Association (ADA) and the American Association of Diabetes Educators (AADE) will each send out the survey link to approximately 30-50 members who offer diabetes self-management education and support (DSMES) services.

1. Are you:

• Male

• Female

2. Are you a diabetes educator or a certified diabetes educator? [mark all that apply]

• Yes, I am a diabetes educator CONTINUE

• Yes, I am a certified diabetes educator CONTINUE

• No, I am not a diabetes educator TERMINATE

3. Do you provide diabetes self-management education and support (DSMES) services offered within a recognized American Diabetes Association (ADA) or accredited American Association of Diabetes Educators (AADE) program?

• Yes CONTINUE

• No TERMINATE

• Not sure TERMINATE

4. When did you last provide DSMES services?

• Under 1 year ago CONTINUE

• 1-5 years ago CONTINUE

• More than 6 years ago TERMINATE

5. How long have you been offering DSMES services? [CAPTURE NUMBER AND CATEGORIZE RESPONSE]

• Under 1 year CONTINUE

• 1-5 years CONTINUE

• 6-10 years CONTINUE

• More than 10 years CONTINUE

6. Roughly what percentage of your patients are…

	0%	1-9%	10-24%	25-49%	50-74%	75-100%	Don’t know
Hispanic or Latino?
Black or African American?

7. Roughly what percentage of your patients…

	0%	1-9%	10-24%	25-49%	50-74%	75-100%	Don’t know
Are insured by Medicare?
Are insured by Medicaid?
Are uninsured?

8. Diabetes educators have many different academic backgrounds and professional certifications. What is your academic/professional background? [Screener: check off which one below, do not list the professions below]

• Registered Nurse CONTINUE

• Nurse Practitioner or Advance Practice Registered Nurse CONTINUE

• Pharmacist CONTINUE

• Dietitian or dietitian nutritionist holding active registration

with the Commission on Dietetic Registration CONTINUE

• Other (capture) ____________________________................................................CONTINUE

9. Which of the following professional associations do you belong to? (Check all that apply)

• American Association of Diabetes Educators CONTINUE

• American Diabetes Association CONTINUE

• Other (specify) CONTINUE