New Mexico Department of Health Participant Survey

 DPCP Standardized Data Collection Form A

Before you enter the training, the Diabetes Prevention and Control Program requests that you kindly take a few minutes to provide them with data that they need to collect for reporting purposes and to improve their program offerings.  Thank you!
Instructions: Complete this form to the best of your ability and click the "Submit Survey!" button at the bottom when complete.
What is your name? * Required
What is your email address? * Required
What is your state of residence? * Required
ABOUT YOU

1. Are you:

Female
Male

2. Are you:

White (Non-Hispanic)
Black or African American
American Indian or Alaska Native
Asian or Pacific Islander
Hispanic
Other (please specify)

3. What language do you speak at home?

English
Spanish
Navajo
Pueblo or other American Indian (please specify)
American Sign Language
Other (please specify)

4. What language do you like best to read and write?

English
Spanish
Navajo
Pueblo or other American Indian (please specify)
Other (please specify)

5. What county/counties do you serve (if you are a New Mexico resident)?

(Ctrl+Click to multiple select)

6a. Do you know about how many people with diabetes you serve? If yes, please provide a number.

6b. If you do not know an approximate number, please estimate a range from the choices below or provide a range.

1-50
51-100
101-300
More than 300
Other (please specify)

7. Where do you work?
Please identify the clinic, office, or organization you work for. (Identify your "home base" if you work in more than one location.)

8. Please select the disciplines or credentials you use for your work in diabetes.

(Ctrl+Click to multiple select)


If "Other" please specify:

9. How many years have you been working in the role(s) you identified above?

Less than 1 year
1 -3 years
More than 3 years

10. How do you keep your knowledge about diabetes and diabetes-related issues up to date? Please check a box under the heading that indicates how often you receive information from the following sources.
  Never Seldom Sometimes More Often Than Not Very Often
Books, magazines, or journals
Newsletters, brochures, or other printed materials
Internet, World Wide Web
CDs
DVDs
Video Tapes
Workshops, Seminars
Diabetes Coordinator or Educator
Other (please specify)

If "Other" please specify:

11. How do you prefer to receive knowledge updates? Select your three (3) favorite ways to receive diabetes training / education.

1.
2.
3.

ABOUT WHO YOU SERVE

Example:

If you have 10 clients and 7 of them are Hispanic, 2 of them are white, and 1 is Native American, then you would complete this answer in the following way:

20% White
0% Black or African American
10% American Indian or Alaska Native, Asian or Pacific Islander
0% Asian or Pacific Islander
70% Hispanic
0% Other
100%  

12. For us to understand the race/ethnicity breakdown of the people you serve, please estimate what percent of your clients belong to the following races/ethnicities.

Please try to adjust your percentages so they add up to 100%.
% White
% Black or African American
% American Indian or Alaska Native
% Asian or Pacific Islander
% Hispanic
% Other (please specify)
Total: %  

13. For us to know the most common spoken language of the people, please estimate the percent of your clients who speak each of the languages listed below.

Please try to adjust your percentages so they add up to 100%.
% English
% Spanish
% Navajo
% Pueblo or other American Indian (please specify)
% American Sign Language
% Other (please specify)
Total: %  

14. Please estimate the percent of your clients who read or write each of the languages listed below.

Please try to adjust your percentages so they add up to 100%.
% English
% Spanish
% Navajo
% Pueblo or other American Indian (please specify)
% Other (please specify)
Total: %  

15. Please estimate the percent of your clients who belong to each of the age groups listed below.

Please try to adjust your percentages so they add up to 100%.
% Females: Under 18
% Females: 18-30 years
% Females: 30-45 years
% Females: 45-65 years
% Females: Over 65 years
Total: %  

% Males: Under 18
% Males: 18-30 years
% Males: 30-45 years
% Males: 45-65 years
% Males: Over 65 years
Total: %  

16. Please estimate the percent of your clients who fit into the categories listed below.

Please try to adjust your percentages so they add up to 100%.
% Do not have any form of diabetes or a family history of diabetes
% Have a close family member with a diagnosis of diabetes
% Have been diagnosed with pre-diabetes
% Have been diagnosed with gestational diabetes
% Have been diagnosed with Type 1 or Type 2 diabetes
Total: %  

17. Please estimate the percent of your clients who fit into the following categories related to how their dental or medical care is paid for.

Please try to adjust your percentages so they add up to 100%.
% They have either private health insurance or health insurance from their employer, and they can afford the co-pays and other costs that the insurance doesn’t pay for, which allows them to receive any dental or medical care they need.
% They have some health insurance or receive some financial assistance that helps pay for their dental and/or medical care costs (including prescriptions), but they cannot afford to get all of the health care they need.
% They are eligible to receive their dental and medical care through the Indian Health Service (IHS).
% They are eligible to receive their dental and medical care through the Veterans Administration (VA).
% They are eligible to receive their dental and medical care through Medicaid.
% They receive assistance with the costs of their dental and/or medical care costs through another agency.
(Please specify)
% They are not eligible to receive any assistance with their dental or medical care costs.
Total: %  

 

Thank you for completing this form.