Form No number No number DDI Health Leadership Clinic Survey

Form Approved

OMB #xxxx-xxxx
EXP. DATE: xx-xx-xxxx

DDI Health Leadership Clinic Survey

Clinic ID ____________

Public reporting burden of this collection of information is estimated to average 1 hour 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-xxxx). Do not send the completed form to this address.

What is this the purpose of the survey?

The purpose of this survey is to obtain information regarding the costs associated with your clinic’s current activities in the areas of diabetes awareness or screening and the number of patients screened or diagnosed. The implementation of the Diabetes Detection Initiative (DDI) was launched in November of 2003. We are asking all clinics that participated in the implementation of the DDI to complete the enclosed survey to determine the type of activities that are still being used, if any. The survey has questions about the medical costs of providing patient care, as well as staff time associated with your clinic’s participation in the diabetes awareness, testing and screening during the previous year.

Completion of this survey is voluntary. You may leave any questions blank that you cannot or do not wish to answer, though we hope you will answer as many questions as you can. Your name will not be on the survey and your answers will have a survey identification number. These survey identification numbers and clinic names will be kept in separate file that will be destroyed upon completion of the study. All information we get in this study will be kept private according to federal laws. Data collected from this survey will be grouped with others answers and reported only in aggregate form so no single respondents answers can be identified.

The survey may take up to an hour to complete as you may need to look up information in your records in order to respond to some questions. If you do not know the exact answer, please provide your best estimate. You will not benefit directly from taking part in this survey; however, the survey will provide the Centers for Disease Control with some of the answers they need in planning and evaluating diabetes screening programs.

If you have any questions about the study, please call us. The task leader for this study, Diane Manninen, PhD can be reached at (206) 528-3140. If you have any concerns about your rights in being part of this study, you may call the Chairperson of the Battelle Institutional Review Board at 1-877-810-9530, extension 500.

Section I. Screening and diagnostic Testing at the Health Clinic

1. Did your clinic provide any of the following diabetes screening and assessment tests at the health clinic during the previous year? If yes, please provide the number or best estimate. Do not include monitoring tests for people with previously diagnosed diabetes. Do not include diabetes screening for gestational diabetes.

	Number	Not Used
a. Paper risk tests
b. Finger sticks to measure blood glucose levels
c. Fasting plasma glucose tests
d. HbA1c test
e. Oral glucose tolerance tests as a follow-up test to verify a preliminary diagnosis of diabetes

2. Which of the following types of staff were involved in diabetes screening and testing activities at the health clinic identified from question 1? Please include participation by unpaid volunteers in the categories that apply.

	Yes	No
a. Nurses, nurse practitioners or physician assistants
b. Public health professionals (epidemiologists, health information officers, health educators)
c. Physicians
d. Laboratory technicians
e. Other (please specify) _________________________

3. What was the total number of hours provided for diabetes screening and testing activities at the health clinic by the staff identified in question 2 during the previous year? For all of the people listed, please consider their level of involvement to calculate total hours for all staff involved in diabetes screening and testing. Please make rough estimates rather than no response. If the time of unpaid volunteers should be included in the table below, please indicate that here, as you did for Question 2.

Type of staff	Hours
a. Nurses, nurse practitioners or physician assistants
b. Public health professionals (epidemiologists, health information officers, health educators)
c. Physicians
d. Laboratory technicians
e. Other (please specify) _________________________
If you do not have an estimate for the hours by each type of staff, please provide total hours
Total Hours for all staff

4. Hours estimated above are:

 based on records or believed to be accurate  best estimate only

5. For the glucose test for diabetes, did your clinic need the assistance of an outside laboratory?

 Yes  No

If yes, what was the amount paid or the estimated value if lab services were not reimbursed?

_______________________

6. During the previous year, how many patients were newly diagnosed with diabetes?

____________________

7. What mechanism do you use to determine this? Please select all that apply.

 registry  physician report  chart review

 lab reports  other, please specify ___________________

Section II. In-Person Outreach

1. Were any clinic staff involved in in-person activities related to diabetes education or screening for the general public (i.e., members of the community who are not your patients)? For example, please include clinic staff participation in booths at a shopping mall, screening at senior housing, health fairs or other community events. Do not include use of radio, television or newspapers in this section but include those in section III. Do not include counseling, education or screening of patients at the clinic.

 Yes

 No (skip to Section III)

2. Which of the following types of staff were involved in-person activities related to public education or screening for the general public? Please include participation by unpaid volunteers in the categories that apply.

Previous year	Yes	No
a. Administrators
b. Nurses, nurse practitioners or physician assistants
c. Public health professionals (epidemiologists, health information officers, health educators)
d. Physicians
e. Clerical
f. Other (please specify) _________________________

3. What was the total number of hours provided for the in-person diabetes education and screening by all clinic staff identified in question 2 during the previous year? For all of the people listed, please consider number of events or occasions, when related activities occurred and their level of involvement to calculate total hours for all staff involved with diabetes screening and testing for the general public. Please make rough estimates rather than no response. If the time of unpaid volunteers should be included in the table below, please indicate that here, as you did for Question 2.

Type of staff	Hours
a. Administrators
b. Nurses, nurse practitioners or physician assistants
c. Public health professionals (epidemiologists, health information officers, health educators)
d. Physicians
e. Clerical
f. Other (please specify) _________________________
If you do not have an estimate for the hours by each type of staff, please provide total hours
Total Hours for all staff

4. Hours estimated above are:

 based on records or believed to be accurate  best estimate only

5. What was the total cost of any materials purchased by your clinic for the in-person outreach activities? Please include the printing or photocopy cost for any other diabetes education brochures distributed by your clinic. Also include purchased or donated materials such as t-shirts, coffee mugs, water bottles, pens, badges, food, water or similar items that were obtained by your clinic to promote diabetes awareness or screening. Enter 0, if none.

a. Printing and photocopy ______________

b. T-shirts, mugs, etc. _______________

Section III. Indirect Outreach

1. Were any clinic staff involved in mass media campaigns to promote diabetes education and awareness? In addition, did staff mail educational brochures or paper risk tests to people who were not patients during the previous year?

Indirect outreach activities include diabetes education when it does not involve contact with potential patients. This may include television, radio or newspaper public service advertisements.

 Yes

 No (skip to Section IV)

2. Which of the following types of staff were involved in outreach and the distribution of paper risk tests? Please include participation by unpaid volunteers in the categories that apply.

Previous year	Yes	No
Administrators
Nurses, nurse practitioners or physician assistants
Public health professionals (epidemiologists, health information officers, health educators)
Community outreach worker/health communication staff
Physicians
Other (please specify) _________________________

3. What was the total number of hours provided for indirect outreach by all clinic staff identified in question 2 during previous year? Do not include participation community events in this category. For all of the people listed, please consider their level of involvement to calculate total hours for all staff involved in indirect outreach. Please make rough estimates rather than no response. If the time of unpaid volunteers should be included in the table below, please indicate that here, as you did for Question 2.

Type of staff	Hours
Administrators
Nurses, nurse practitioners or physician assistants
Public health professionals (epidemiologists, health information officers, health educators)
Community outreach worker/health communication staff
Physicians
Other (please specify) _________________________
If you do not have an estimate for the hours by each type of staff, please provide total hours
Total Hours for all staff

4. Hours estimated above are:

 based on records or believed to be accurate  best estimate only

5. What was the total cost of any materials purchased by your clinic for the diabetes education and awareness used in mass distributions? Please include the printing or photocopy cost for any other diabetes education brochures or handouts mailed by your clinic. If mailed, include postage. Also, include the cost of radio or television air time and newspaper advertisements. If these were donated, please estimate their value. Enter 0, if none.

a. Printing and photocopy ______________

b. Postage _______________

c. Media advertisements _______________

THANK YOU FOR YOUR TIME AND EFFORT IN PARTICIPATING IN THIS SURVEY. PLEASE RETURN THE COMPLETED SURVEY
IN THE POSTAGE PAID ENVELOPE TO:

Diabetes Detction Iniative (DDI) Study Office

Battelle Seattle Research Center

1100 Dexter Avenue N, Suite 4000

Seattle, WA 98109-3598

Page 9