CDSME Participant Information Survey

OMB Control No. 0985-0036
Exp. Date XX/XX/20XX

Program Name
Participant Information Survey
Admin Use Only: Participant I.D.: The facilitator or program staff should complete this part of the form and mark the
sequential number of the participant to the name on the attendance form.
State abbreviation : __ __ (e.g., NY, VA, etc.)
First four letters of the site name : __ __ __ __
Start date of program : __ __ / __ __ / __ __ (e.g., 12/01/19)
Participant number : __ __ (e.g., 01, 02, 03, etc.)

1. Did your doctor or other health care provider suggest that you attend this program?
2. How old are you today?__________ years
3. Do you live alone?

Yes

No

4. Are you of Hispanic, Latino, or Spanish origin?

Yes

No

5. What is your race? Check all that apply.
 American Indian or Alaska Native
 Asian
 Black or African American
 Native Hawaiian or other Pacific Islander
 White
 Some other race (please specify) _________________
6. What is your current gender (select one)?
 Man
 Woman
 Non-binary
 __________________________ (please specify)
 Prefer not to answer
7. Do you consider yourself to be transgender?
 Yes
 No
 Prefer not to answer
8. Which of the following best represents how you think of yourself? [Select ONE]:
 Lesbian or gay
 Straight, that is, not gay or lesbian
 Bisexual
 [If respondent is AIAN:] Two-Spirit
 I use a different term (please specify): _________________
 Don’t know
 Prefer not to answer

Yes

No

OMB Control No. 0985-0036
Exp. Date XX/XX/20XX

9. What is the highest grade or year of school you completed?
 Some elementary, middle, or high school
 Some college of technical school
 High school graduate or GED
 College (4 years or more)
10. Have you ever served in the military?

Yes

No

11. During the past year, did you provide regular care or assistance to a friend or family
member who has a long-term health problem or disability?
Yes
No
12. In general, would you say that your health is:
Excellent
Very Good
Good

Fair

Poor

13. Has a health care provider ever told you that you have any of the following chronic conditions (i.e., one
that has lasted for three months or more)? Please use an X to indicate your response Yes or No
YES NO
YES NO
Alzheimer’s Disease or other
Kidney Disease
Dementia
Anxiety Disorder
Malnutrition
Arthritis/Rheumatic Disease
Obesity
Asthma/Emphysema/Other Chronic
Breathing or Lung Problem
Cancer or Cancer Survivor

Osteoporosis (Low Bone Density)

Chronic Pain

Schizophrenia or other Psychotic
Disorder
Stroke
Substance Use Disorder
Urinary Incontinence
Other Chronic Condition

Depression
Diabetes (High Blood Sugar)
Heart Disease
High Cholesterol
Hypertension (High Blood Pressure)

Post-Traumatic Stress Disorder

14. Please use an X to indicate your response to the following questions.
YES NO
a. Are you deaf or do you have serious difficulty hearing?
b. Are you blind or do you have serious difficulty seeing, even when wearing glasses?
c. Do you have serious difficulty walking or climbing stairs?
d. Do you have difficulty dressing or bathing?
e. Because of a physical, mental, or emotional condition, do you have serious difficulty
concentrating, remembering, or making decisions?
f. Because of a physical, mental, or emotional condition, do you have difficulty doing
errands alone such as visiting a doctor’s office or shopping?

OMB Control No. 0985-0036
Exp. Date XX/XX/20XX

15. How often do you feel lonely?
 Always
 Often

 Sometimes

 Rarely

 Never

16. How often do you feel isolated from those around you?
 Always
 Often
 Sometimes
 Rarely

 Never

17. How sure are you that you can manage your condition so you can do the things you need and want to do?
Totally unsure

1

2

3

4

5

6

7

8

9

10

Totally sure

OMB Control No. 0985-0036
Exp. Date XX/XX/20XX

TO BE COMPLETED AT LAST PROGRAM SESSION
Admin Use Only:
Participant I.D.: The facilitator or program staff should complete this part of the form and mark the sequential number of
the participant to the name on the attendance form.
State abbreviation : __ __
(e.g., NY, VA, MA, etc.)
First four letters of the site name : __ __ __ __
Start date of program : __ __ / __ __ / __ __ (e.g., 12 01 19)
Participant number : __ __ (e.g., 01, 02, 03, etc.)

1. In general, would you say that your health is:
Excellent
Very Good
Good

Fair

Poor

2. How sure are you that you can manage your condition so you can do the things you need and want to do?
Totally unsure

1

3. How often do you feel lonely?
 Always
 Often

2

3 4 5 6 7 8

 Sometimes

9 10

Totally sure

 Rarely

 Never

4. How often do you feel isolated from those around you?
 Always

 Often

 Sometimes

 Rarely

 Never

5. Since this program began, what have you done to manage your chronic condition(s)? Check all that
apply







Talked to a family member or friend about my health
Talked to a healthcare provider about how I can better manage my chronic condition
Had my medications reviewed by a healthcare provider or pharmacist
Started or continued to exercise
Made changes to how I choose the food I eat
Participate in or plan to participate in another health-related or exercise program in my
community

6. How would you rate your overall satisfaction with the quality of the program?
 Very Dissatisfied

 Dissatisfied

 Okay

 Satisfied

 Very Satisfied

Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless such collection displays a valid OMB control number (OMB 0985-0036). Public reporting
burden for this collection of information is estimated to average .20 hours per response, including time for
gathering and maintaining the data needed and completing and reviewing the collection of information. The
obligation to respond to this collection is voluntary.