0920-0572 Person with DM had DSMES Survey

OMB No. 0920-0572

Expiration Date 3/31/2021

MESSAGE TESTING CARD SORT SURVEY FOR PEOPLE WITH DIABETES (PWD) WHO HAVE HAD DSMES

September 19, 2019

To be included on the first page: 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 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). 

FOR PEOPLE WITH DIABETES WHO HAVE HAD DSMES

Introduction: Thank you for agreeing to participate. We are interested in how people with diabetes choose among different services to help them manage their conditions.

This survey asks you about the diabetes self-management education and support services that you were referred to by your health care provider. [INSERT PLAIN LANGAUGE DESCRIPTION HERE]

1. From the list of words below, please select up to 5 qualities that best describe what you would consider to be ideal diabetes self-management education and support services (services you would give a grade of A+). (SELECT NO MORE THAN 5)

[INSERT LIST OF POSITIVE WORDS; RANDOMIZE OPTIONS] 

2. Why did you choose each of these five qualities instead of the others? What’s important about them? [SHOW THE WORDS SELECTED IN Q1] [OPEN ENDED TEXT BOX]

2. Thinking about these five qualities of ideal diabetes self-management education and support services, please rank them in order of importance to you, with 1 being the most important, 2 being the second most important, and so on.

(SHOW LIST THAT THEY CHOSE IN Q1 IN RANDOM ORDER; HAVE THEM RANK THE WORDS 1 TO 5) 

2. Would you say that the diabetes self-management education and support services that you received were …

1. Excellent

2. Very Good

3. Good

4. Fair

5. Poor

2. Which of the following words or phrases, if any, describe the actual diabetes self-management education and support services you received? (SELECT ALL THAT APPLY) 

[INSERT LIST OF POSITIVE WORDS; RANDOMIZE OPTIONS] 

2. Now I want to show you another list of words or phrases. Which of the following words or phrases, if any, describe the actual diabetes self-management education and support services you received? [SELECT ALL THAT APPLY] 

[INSERT LIST OF NEGATIVE WORDS; RANDOMIZE OPTIONS; INCLUDE AN “OTHER/SPECIFY”]