Form 9 Intervention Participant Recruitment Guide

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Form Approved OMB # XXXX-XXXX

Exp. Date XX/XX/2017

ommunity Evaluation of The National Diabetes Education Program’s

Diabetes HealthSense Website – Recruitment Guide

INSTRUCTIONS: Please use this guide as you recruit individuals to participate in the Diabetes HealthSense Website evaluation project. This guide will help you ensure that the participants fit the evaluation criteria, and track their participation in the program.

Public reporting burden for this collection of information is estimated to average 15 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.

Recruitment								Participation Confirmation
Participant Name	Participant is 35 yr old or older.	Diabetes Status*			Participant has regular internet access	Participant reports regularly internet use	Participant reports English language proficiency***	Reviewed Consent form with Participant	Participant has completed online consent and Pretest	Confirmed Participation within one week of program
		Type 2*	Pre diabetes*	At Risk**

* Participants must have received a diagnosis of Type 2 Diabetes or prediabetes within the last 5 years to participate in this evaluation.

**Participants must have a score of 5 or higher on the ADA risk test in order to participate in this evaluation.

***Participant can speak, read and write in English at the level needed to: -Participate in group, Read information on the DHS website, Complete surveys.