3C - NDEP DHS Participant Exit Satisfaction Survey_091913_OMB30

Diabetes HealthSense Education Program Participant Exit Survey

[Date and Time Stamp]

The National Diabetes Education Program is trying to find out how people feel about the Diabetes HealthSense Website and the education session you participated in today. By telling us your honest feelings in this survey, you will help improve Diabetes HealthSense.

This survey will take you about 10 minutes to complete. It asks questions about the Diabetes HealthSense program you participated in today, the website in general, the content or resources found on the website, and your plans for using Diabetes HealthSense over the next month. Unless the directions say otherwise, please choose one response for each question.

Public reporting burden for 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: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-xxxx*). Do not return the completed form to this address.

ID Code

To keep your responses private an ID code will be created using the following information.

Please write down YOUR first and last initials: [Example: Jane Smith is J.S.; Jane Doe-Smith is J.D.]

First Initial Last Initial

What is your MONTH and YEAR of BIRTH? [Ex: Write 05/95 if your birthday is May 22, 1995]

____ / ____ MM YY

Please choose your program location?

 Site 1  Site 2  Site 3  Site 4  Site 5

 Site 6  Site 7  Site 8  Site 9  Site 10

 Site 12  Site 12  Site 13  Site 14  Site 15

Experience and Satisfaction with Today’s Session

1. As part of today’s session, I was shown: (Check one or more)

 An introduction to Diabetes HealthSense

 How to use the Diabetes HealthSense website

 How other individuals and families use Diabetes HealthSense

 How to use Make a Plan to set goals and to develop a plan to achieve those goals

 How to find resources to help me lose weight or eat healthy

 How to find resources to help me stay or become active

How much did you like the following parts of today’s Diabetes HealthSense session?	Did not like at all	Liked a little	Liked	Liked a lot
The Diabetes HealthSense PowerPoint presentation				
Having the trainer use examples from group members to show how Diabetes HealthSense could be used				
Looking at Diabetes HealthSense on my own				
Working with others in the group				
Having the trainer there to help me if I needed it				
The length of the session				
The overall structure of the session				

How easy would it have been to find resources on Diabetes HealthSense if you had not attended today’s program? It would have been:
 Not easy at all	 A little easy	 Easy	 Very easy

4. How much do you agree or disagree with the following statements about the trainer who worked with you today?

My Trainer…	Strongly disagree	Disagree	Agree	Strongly agree
Thorough				
Was well prepared for this session.				
Was friendly and there for my needs.				
Spent the right amount of time with each participant.				

Which of the following topics found on Diabetes HealthSense did you review on your own today? (Check one or more.)
 Eating healthy	 Setting goals
 Being active	 Stopping smoking
 Managing my weight	 Checking my blood sugar
 Coping with stress and emotions

6. Which of the following types of resources did you look at on Diabetes HealthSense today? (Choose one or more)

 Printable documents (e.g., fact sheets, brochures, booklets, research articles)

 Videos

 Podcasts

 Presentations

 Tracking tools (e.g., tools you can use to keep track of what you eat, your physical activity or your blood glucose level)

 Online programs

 Information about in-person programs

 Mobile applications

 Other (please specify):________________________

Satisfaction with Diabetes HealthSense

How much do you agree or disagree that each of the following words describes the Diabetes HealthSense website?	Strongly Disagree	Disagree	Agree	Strongly Agree
Attractive				
Overwhelming				
Useful				
Trustworthy				
Hard to use				
Time-consuming				
Thorough				
Confusing				

How much do you agree or disagree with the following statements?	Strongly Disagree	Disagree	Agree	Strongly Agree
I will recommend this website to friends and/or family who are also have diabetes				
I will share the information and resources I found on this website with others.				

How much do you agree or disagree with the following statements about the resources on Diabetes HealthSense?

I found resources that will help me…	Strongly Disagree	Disagree	Agree	Strongly Agree
Learn more about the disease diabetes.				
Learn more about how to prevent or manage diabetes.				
Be more confident in taking actions to prevent or manage my diabetes.				
Eat healthy.				
Be active.				

10. What do you like about Diabetes HealthSense?

11. What should be changed about Diabetes HealthSense?

Future Plans

During the next month, how likely are you to return to the Diabetes HealthSense website to…	Not at all likely	Somewhat likely	Likely	Very Likely
Find more information and resources using Diabetes HealthSense?				
Use the resources you find on Diabetes HealthSense?				
Tell others about Diabetes HealthSense?				
Show others how to use Diabetes HealthSense?				

During the next month, how likely are you to return to the Diabetes HealthSense website to help you…	Not at all likely	Somewhat likely	Likely	Very Likely
Learn more about diabetes?				
Learn more about how to prevent or manage diabetes?				
Eat healthier?				
Be more active?				
Better manage your weight?				
Cope better with stress and emotions?				
Set goals?				
Stop smoking?				
Better track your blood sugar?				

14. During the next month, how often will you return to the Diabetes HealthSense Website?

 Never

 Rarely (Just once or twice)

 Sometimes (Once a week)

 Often (2-3 times a week)

 Daily

National Diabetes Education Program Participant Exit Satisfaction Survey 9/19/13 5