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 work?

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

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

(Ctrl+Click to multiple select)

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

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

(Ctrl+Click to multiple select)


If "Other" please specify:

ABOUT WHO YOU SERVE

7. Estimate what percent of your clients belong to the following race/ethnicities.

Please 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: %  

8. Estimate the percent of people you serve from each gender:

Please adjust your percentages so they add up to 100%.
Male Female Total
% % %

9. Estimate the percent of people you serve from each age group:

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

 

Thank you for completing this form.