0920-19BOI Pre Session Survey

Study ID Number:

Form Approved

OMB No. 0920-xxx

Exp. Date xx/xx/xx

PRE-SESSION SURVEY

Welcome to today’s introductory session. Today’s session has been selected to be evaluated by the Centers for Disease Control and Prevention to better understand how Introductory Sessions can help increase enrollment into the National Diabetes Prevention Program Lifestyle Change Program like the one you will learn about today. Before the introductory session begins, please take a few minutes to answer the following questions. The information that you share will help CDC and the Lifestyle Change Program team understand some of the reasons why people like you decide to participate in programs that are designed to prevent or delay type 2 diabetes. Your responses will remain anonymous and cannot be traced back to you. This survey should take no more than 5 minutes to complete.

Completing this survey is voluntary. You may choose not to answer any questions or end the survey at any time without any penalty. Your decision to complete this survey will not affect your ability to take part in today’s introductory session or the National DPP lifestyle change program that you will learn more about today.

CDC estimates the average public reporting burden for this collection of information as 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxx).

Before we start the session, please answer the following questions.

1. How did you hear about us? (check all that apply)

• Referral from friend or family

Did this person take part in a lifestyle change program or are they currently enrolled in a lifestyle change program?  Yes  No

• Referral from a doctor or other health care provider

• Program material (handout, pamphlet, etc.)

• Other, please specify: _________________________________________________________

2. Have you ever taken part in a lifestyle change program to prevent type 2 diabetes before today?

• Yes

• No

3. Has your doctor ever told you that you have diabetes?

• Yes

• No

4. Has your doctor ever told you that you are at-risk of getting type 2 diabetes?

• Yes

• No

5. On a scale of 1 = very unlikely to 5 = very likely, how likely do you think you are to get type 2 diabetes in your lifetime?

							
1	2		3		4		5
Very unlikely						Very likely

6. How strongly do you disagree or agree with each statement listed below? (select one answer for each statement)

It will be hard for me to change my lifestyle to prevent or delay type 2 diabetes.	 Strongly disagree	 Disagree	 Neither agree nor disagree	 Agree	 Strongly agree
I see myself as someone who would benefit from taking part in a lifestyle change program to prevent or delay type 2 diabetes.	 Strongly disagree	 Disagree	 Neither agree nor disagree	 Agree	 Strongly agree
I am not sure that I can take part in a lifestyle change program that requires me to attend weekly classes.	 Strongly disagree	 Disagree	 Neither agree nor disagree	 Agree	 Strongly agree
I feel comfortable being here with other people who are interested in preventing or delaying type 2 diabetes.	 Strongly disagree	 Disagree	 Neither agree nor disagree	 Agree	 Strongly agree
Taking part in a lifestyle change program is worth the time because I will be healthier in the future.	 Strongly disagree	 Disagree	 Neither agree nor disagree	 Agree	 Strongly agree
I think that it is important to take part in a lifestyle change program to prevent or delay type 2 diabetes as soon as possible.	 Strongly disagree	 Disagree	 Neither agree nor disagree	 Agree	 Strongly agree

7. When are you planning to sign up for a National DPP lifestyle change program to prevent or delay type 2 diabetes?

• Today

• Next week

• Next month

• Next year

• I am not sure

• I do not plan to sign up for a lifestyle change program

8. With which race do you identify? (check all that apply)

• American Indian or Alaska Native

• Asian

• Black or African American

• Native Hawaiian or other Pacific Islander

• White or Caucasian

• Other, please specify ________

• I prefer not to answer

9. Are you Hispanic or Latino?

• Yes

• No

• I prefer not to answer

10. What type of insurance do you have? (check all that apply)

• I do not have insurance

• Medicaid

• Medicare

• Private insurance

• Military health care

• Other, please specify: ___________________________________

11. What is your gender?

• Male

• Female

• Other, please specify: ___________________________________

• I prefer not to answer

12. What is your age?

• 18–34

• 35–44

• 45–54

• 55–64

• 65–75

• 75+

Thanks for this information! Please return this survey to a staff member when you are finished.

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