DSMES Provider Screener Script and Guidelines

OMB No. 0920-1154
Expiration date: 03/31/2026

Attachment A: DSMES Provider Screener Script and Guidelines

Diabetes Education and Support Service Providers Who Support Disproportionately Affected Populations (DAPs)

Hello. My name is [name]. I work with FHI 360, a nonprofit organization. We received your name from _______________________ [referral source].

We are looking to talk with diabetes care and education specialists and other program staff who provide diabetes self-management education and support services or other supports to persons with type 2 diabetes. We are conducting this work on behalf of the U.S. Centers for Disease Control and Prevention, also known as CDC. If you qualify and take part in a listening session with other DSMES providers, you will receive $150 electronic gift card as a token of appreciation. The session will be conducted using an online meeting platform and should take about 60 minutes.

To see if you qualify, I would like to ask you a few questions. These questions will take less than 5 minutes to answer and we will keep your answers confidential. May I continue?

• Agreed to answer screening questions Continue

• Did not agree to answer screening questions Thank and Terminate

Please use the following language for termination of screening:

Thank you very much for your time today. Unfortunately, you do not meet the criteria for these listening sessions. Again, thank you for taking the time to speak with me today.

1. Do you currently provide or oversee a diabetes self-management education and support services (also known as DSMES) that is part of a program that is recognized by the American Diabetes Association (ADA) or accredited by the Association of Diabetes Education Specialists (ADCES), formally known as American Association of Diabetes Educators?

• Yes Go to Q3

• No Continue to Q2

• Not sure Continue to Q2

Public Reporting Burden Statement   

Public reporting burden of this collection of information is estimated to average 5 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (09200572)

2. Do you currently provide other types of education or support services to help people with type 2 diabetes manage their condition?

• Yes [describe] Continue to Q3

• No Terminate

• Not sure Terminate

3. We are interested in talking to professionals who support Disproportionately Affected Populations (DAPs) with diabetes in managing their diabetes. What are the main populations that you serve? [ENTER RESPONSE AND CHECK ALL THAT APPLY]

Describe populations they serve: _____________________________________

• African American women (and men) Continue

• Hispanic women (and men) Continue

• AA/PI women (and men) Continue

• AI/AN women (and men) Continue

• People with learning disabilities Continue

• People with mental health disorders Continue

• Other Terminate

[IF THEY SERVE MEN AND WOMEN, EQUALLY, THEY COULD BE INCLUDED. EXCLUDE IF THEY FOCUS ON MEN WHO ARE RACIAL/ETHNIC MINORITIES]

4. Do you adjust or tailor your diabetes self-management support services to [DAP audiences selected in Q3] to address the unique needs of [DAP audience]?

• Yes [describe] Continue to Q3

• No Terminate

• Not sure Terminate

5. How long have you been providing diabetes education and support services? [RECRUIT A MIX, RECRUIT AT LEAST 1 PER CATEGORY]

• Less than 1 year Terminate

• 2-5 years Continue

• 5-10 years Continue

• More than 10 years Continue

6. What type of organization do you work for that provides these support services? [RECRUIT A MIX]

• A large health system Continue

• Hospital Continue

• Physician group practice Continue

• Solo practice Continue

• FQHC Continue

• Nutrition service Continue

• Community organization [describe:_____________________ Continue

• Other [describe:______________________________________  Continue

7. In which state is your program located? [CAPTURE STATE ____ AND RECRUIT A MIX OF REGIONS]

8. What is your academic/professional background?

• Diabetes care and education specialist (not certified) Continue

• Certified diabetes care and education specialist Continue

• Dietitian or dietitian nutritionist Continue

• Registered Nurse (other than NP or APRN) Continue

• Nurse Practitioners/Advance Practice Registered Nurse Continue

• Pharmacist Continue

• Physician assistant Continue

• Physician [specialty]:_________________________________ Continue

• Other [describe]:______________________________________  Continue

Invitation

Thank you for answering my questions. We would like to invite you to participate in a listening session via Zoom that will last no more than 60 minutes. (A listening session, like a focus group, is a facilitated discussion with a group of people, aimed at collecting information about their experiences.) As a token of appreciation, you will receive $150 in the form of an e-gift card (VISA or MasterCard) for participating. The listening session will be recorded so I can write an accurate report. The recording will be destroyed no later than April 2028. Members of the CDC team may be sitting in on the listening session. We will not use any information that could identify you in our report to the CDC, and during the listening session, we will only use first names and will refrain from mentioning the name of your organization.

Are you interested in participating?

• Yes [SCHEDULE TIME]

• No Thank and Terminate

For Scheduling

We will send you a confirmation email and information about the listening session. What is your contact information?

[RECORD APPROPRIATE CONTACT INFORMATION]

Name________________________________________________________________________

Address______________________________________________________________________

City/State/Zip_________________________________________________________________

Day Phone Number____________________________________________________________

Evening Phone Number___________________________________________________________

Email address_________________________________________________________________

Which is the best number to reach you? ____________________________________________

What is the best time to reach you? (incl time zone) ____________________________________

So that we can start and end on time, please plan to be dialed into the call and logged into the online meeting platform 5 minutes before the scheduled start time. We are counting on your participation, so please be sure to contact us as soon as possible if something comes up and you cannot be part of the listening session. [PROVIDE NAME AND PHONE NUMBER]

Thanks again for your time and we’ll talk with you at [date/time].

Attachment A: DSMES Provider Screener Script and Guidelines 4

Formative Evaluation, Implementation and Rapid Evaluation (FIRE) of

Diabetes Self-Management in Disproportionately Affected Populations (DAPs)