Form Attachment 22 Attachment 22 Attachment 22 -- HC Diabetes SAQ - Proxy

32087

Form Approved
OMB #0935-0118
Exp. Date 12/31/2018

Proxy

2018

A Survey About Diabetes Care
The care of people with diabetes is an important concern of the U.S. Department
of Health and Human Services. We would appreciate it if you would take a few
minutes to answer the following questions on the care your family member received
for his or her diabetes. Your participation is voluntary and all of the answers will
be kept confidential to the extent permitted by law. If you have any questions
about this survey, please call Alex Scott at 1-800-945-MEPS (6377).
This survey should
be completed for  NAME:

DOB:

/
MONTH

/
DAY

YEAR

PID:

RUID:
When you have completed the survey, return it to your interviewer.

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the
Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have
consented to that disclosure. Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time
required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ,
5600 Fishers Lane Room #07W42, Rockville, MD 20857.

The Agency for Healthcare Research and Quality and
The Centers for Disease Control and Prevention of the
U.S. Department of Health and Human Services

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A Survey About Diabetes Care
Instructions: Answer each question by marking one box  or filling in a number when
necessary. If you are unsure about how to answer a question, please give the best
answer you can. In the questions below, "(NAME)" refers to the person listed in the
box on the front page.
A health professional could be a general doctor, a specialist doctor, a nurse practitioner,
a physician assistant, a nurse, or anyone else you would see for health care.
1. Has (NAME) ever been told by a doctor or
other health professional that he/she has
diabetes or sugar diabetes?
MARK  ONE.

3. Which of the following year(s) did a doctor
or other health professional check (NAME)'s
feet for any sores or irritations?
MARK  ALL THAT APPLY.

Yes  Please continue.

During 2018

No  Thank you for your time.

During 2017

This survey is complete.

During 2016

Before 2016
2. During 2017, how many times did a doctor,
nurse, or other health professional check
Never
(NAME)'s blood for glycosylated hemoglobin
4. Which of the following year(s) did (NAME)
or "hemoglobin A-one-C"?
have an eye exam in which his/her pupils
(A1C is a blood test to monitor the glucose level of
diabetes over a period of several months. The A1C test
were dilated? This would have made (NAME)
is usually done in a lab, hospital, or doctor's office
temporarily sensitive to bright light.
although a home kit containing materials for one or two
tests is now available. The A1C test is not the same as
MARK  ALL THAT APPLY.
a Home Glucose Monitoring test which is used at home
to monitor glucose levels on a daily or weekly basis,
and needs supplies of disposable test strips.)

During 2018
During 2017

If (NAME) had this blood test, fill in
NUMBER OF TIMES

During 2016
Before 2016

Did not have A1C blood test
Don't know
Never

Never
5. Which of the following year(s) did (NAME)
have his/her blood cholesterol checked?
MARK  ALL THAT APPLY.
During 2018
During 2017
During 2016
Before 2016
Never

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6. Which of the following year(s) did (NAME)
get a flu vaccination (shot or nasal spray)?
MARK  ALL THAT APPLY.
During 2018
During 2017
During 2016
Before 2016
Never
7. Has (NAME)'s diabetes caused problems
with his/her kidneys?
Yes
No

11. Is (NAME)'s diabetes being treated with
insulin injections?
Yes
No
12. During the last 12 months, has (NAME)
learned how to take care of his/her diabetes?
Yes
No  Go to Question 14


13. Which of the following methods has (NAME)
used to learn to take care of his/her diabetes?
MARK  ALL THAT APPLY.
Talking to a doctor/health professional
within his/her primary care practice

8. Has (NAME)'s diabetes caused problems
with his/her eyes that needed to be treated
by an ophthalmologist?

Talking to a doctor/health professional
not in his/her primary care practice
Telephone call with a
health professional
Reading about it on the Internet

Yes
No
9. Is (NAME)'s diabetes being treated by
modifying his/her diet?
Yes
No
10. Is (NAME)'s diabetes being treated by
medications taken by mouth?
Yes
No

Taking a group class
Other (specify)

14. How confident is (NAME) in taking care of
his/her diabetes?
Not confident at all
Somewhat confident
Confident
Very confident
Refused
Don't know

 PLEASE CONTINUE TO THE BACK COVER.

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Thank you for taking the time to complete this important survey.
Please remember to return it to your interviewer.
Date completed:

MONTH

DAY

YEAR

Who completed the survey for the person named on the front page?

What is this person's relationship to the person named on the front page?
Husband or wife
Unmarried partner

Mother, father, or guardian
Son or daughter

Other relative
Not related

What is the reason the person named on the front page did not complete the survey himself/herself?

Data Year 2017
18-231

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