0920-19BOI Post- Session Survey

Study ID Number:

Form Approved

OMB No. 0920-xxx

Exp. Date xx/xx/xx

POST-SESSION SURVEY

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. Now that you have completed the introductory session, please take a few minutes to answer the following questions before you leave. The information that you share will help CDC and the Lifestyle Change Program team better understand some of the reasons why people like you decide to take part in programs that are designed to prevent or delay type 2 diabetes. This survey should take no more than 10 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 the National Diabetes Prevention Program lifestyle change program that you learned about during today’s introductory session.

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).

1. 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

2. 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

3. 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 National DPP lifestyle change program

• Why do you not plan to sign up for a lifestyle change program?

If you answered ‘I do not plan to sign up for a National DPP lifestyle change program’ to Question 3,

skip to Question 7.

4. How much do you disagree or agree with the following statement?

Today’s introductory session was important in my decision to sign up for a lifestyle change program (now or in the future).

				
Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree

5. Why do you plan to sign up for a lifestyle change program? Mark all statements that apply to you.

• A friend or family member encouraged me to do it.

• My doctor (or other health care provider) referred me and/or recommended the program.

• I like the idea of being in a program with other people with the same goals.

• I like the idea of being in a structured program.

• What I learned during the introductory session about type 2 diabetes.

• I want to lose weight.

• I want to learn how to eat better.

• I’ve been looking for an exercise and nutrition program and this one seems good.

• Other reason (please explain): _______________________________________________

6. Which one of these reasons is the MAIN reason you plan to sign up for a lifestyle change program? Select only one reason.

• A friend or family member encouraged me or asked me to do it.

• My doctor (or other healthcare provider) referred me and/or recommended the program.

• I like the idea of being in a program with other people with the same goals.

• I like the idea of being in a structured program.

• What I learned during the introductory session about type 2 diabetes.

• I want to lose weight.

• I want to learn how to eat better.

• I’ve been looking for an exercise and nutrition program and this one seems good.

• Other reason (please explain): _______________________________________________

7. Thinking about today’s introductory session, how would you rate the following statements?

In general, how clear was the session leader’s explanation of the activities during the session?	 1 Not clear	 2	 3 Somewhat clear	 4	 5 Very clear	 N/A
How much of the information presented today did you understand?	 1 Understood little	 2	 3 Understood some	 4	 5 Understood a lot	 N/A
How often did you take part in activities and discussions?	 1 Never	 2	 3 Some of the time	 4	 5 All of the time	 N/A
How much did the session leader answer your questions and concerns?	 1 None of my questions and concerns	 2	 3 Some of my questions and concerns	 4	 5 All of my questions and concerns	 N/A
How much did the session leader(s) take the time to get to know you?	 1 Not at all	 2	 3 Some	 4	 5 A lot	 N/A
Was attending today’s introductory session worthwhile?	 1 Not at all worthwhile	 2	 3 Somewhat worthwhile	 4	 5 Very worthwhile	 N/A

Again, thank you! Please give this survey to a staff member before you leave.