0920-0572 Screener People with DM

OMB No. 0920-0572

Expiration Date 3/31/2021

MESSAGE TESTING CARD SORT SCREENER FOR PEOPLE WITH DIABETES

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). 

People with Diabetes Screener

1. Gender

• Male CONTINUE

• Female CONTINUE

2. What is your age?

• Under 18 TERMINATE

• 18-44 CONTINUE

• 45-64 CONTINUE

• 65 or over CONTINUE

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

• Yes TERMINATE

• No CONTINUE

4. Do you, or does any member of your household or immediate family, work in a medical office or pharmaceutical company?

• Yes TERMINATE

• No CONTINUE

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

• Yes CONTINUE

• No TERMINATE

• Do not know/Unsure TERMINATE

6. What type of diabetes have you been diagnosed with??

• Type 1 CONTINUE

• Type 2 CONTINUE

• Gestational TERMINATE

• Iatrogenic hyperglycemia/Cancer related TERMINATE

• Do not know/Unsure TERMINATE

7. When were you diagnosed with diabetes?

• Less than 2 years ago CONTINUE

• More than 2 years ago CONTINUE

8. Has a health care provider ever referred you to diabetes education services? I am specifically referring to [INSERT PLAIN LANGUAGE DESCRIPTION HERE].

• Yes CONTINUE

• No CONTINUE

• Do not know/Unsure TERMINATE

9. Are you currently working with a diabetes educator to help you manage your diabetes?

• Yes CONTINUE

• No CONTINUE

• Unsure TERMINATE

10. In the past 12 months, have you received or participated in diabetes self-management, education, and support services that were provided by a diabetes educator? I am specifically referring to [INSERT DSMES PLAIN LANGUAGE DESCRIPTION HERE].

• Yes CONTINUE

• No CONTINUE

• Do not know/Unsure TERMINATE

11. Have you ever participated in diabetes education to which your health care provider referred you? I am specifically referring to [INSERT DSMES PLAIN LANGUAGE DESCRIPTION HERE].

• Yes CONTINUE

• No CONTINUE

• Do not know/Unsure TERMINATE

12. Approximately how many hours of diabetes education have you participated in?

• Less than 1 hour CONTINUE

• 1-5 hours CONTINUE

• 6-10 hours CONTINUE

• More than 10 hours CONTINUE

13. 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

14. Which of the following best describes 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 or higher CONTINUE

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

• Other: _____________________ TERMINATE

16. What is your race or ethnic background? Are you …?

Ethnicity:

• Hispanic or Latino CONTINUE

• Not Hispanic or Latino CONTINUE

Race: (select all that apply)

• White CONTINUE

• Black or African-American CONTINUE

• American Indian or Alaska Native CONTINUE

• Native Hawaiian or Other Pacific Islander CONTINUE

• Asian CONTINUE