Form Approved
OMB #0935-0118
Exp. Date 01/31/2013
Self 2011
Medical Expenditure Panel Survey (MEPS)
A Survey About Your Diabetes Care
The care of people with diabetes is an important concern of the U.S. Department of
Health and Human Services. Please take a few minutes to answer the following
questions on the care you received for your diabetes. Your participation is voluntary and all of
your answers will be kept confidential to the extent permitted by law. If you have any questions about this survey,
please call Alex Scott at 1-800-945-MEPS (6377).
This survey should
be completed by |
NAME: ________________________
_______________________________
DOB: |
__________ |
PID: |
__________ |
RUID: |
_________________________ |
|
When you have completed the survey, please fold it, seal it with this label, and place it in the envelope provided.
Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). That law requires that information collected for research conducted or supported by AHRQ that identifies individuals or establishments be used only for the purpose for which it was supplied unless you consent to the use of the information for another purpose. Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time required to complete the survey. 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: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.
The Agency for Healthcare Research and Quality and
The Centers for Disease Control and Prevention of the
U.S. Department of Health and Human Services. OMB # 0935-0118
A Survey About Your Diabetes Care
Instructions: Answer every question by checking one box or filling in a number as indicated. If you are unsure about how to answer a question, please give the best answer you can.
A health professional could be a general doctor, a specialist doctor, a nurse practitioner, a physician assistant, a nurse, or anyone else you would see for health care.
1. |
Have you ever been told by a doctor or
other health professional that you have diabetes or sugar
diabetes? (CHECK ONE) |
|
Yes |
Please continue. |
|
No |
Thank you for your time. This survey is complete. |
7. |
Has your diabetes caused problems with your kidneys? |
|
Yes |
![empty check box](images/empty_checkbox.gif) |
|
No |
![empty check box](images/empty_checkbox.gif) |
8. |
Has your diabetes caused problems with your eyes that needed to be treated by an ophthalmologist? |
|
Yes |
![empty check box](images/empty_checkbox.gif) |
|
No |
![empty check box](images/empty_checkbox.gif) |
9. |
Is your diabetes being treated by modifying your diet? |
|
Yes |
![empty check box](images/empty_checkbox.gif) |
|
No |
![empty check box](images/empty_checkbox.gif) |
10. |
Is your diabetes being treated by medications taken by mouth? |
|
Yes |
![empty check box](images/empty_checkbox.gif) |
|
No |
![empty check box](images/empty_checkbox.gif) |
11. |
Is your diabetes being treated with insulin injections? |
|
Yes |
![empty check box](images/empty_checkbox.gif) |
|
No |
![empty check box](images/empty_checkbox.gif) |
12. |
During the last 12 months, have you learned how to take care of your diabetes? |
|
Yes |
![empty check box](images/empty_checkbox.gif) |
|
No (skip Q 14) |
![empty check box](images/empty_checkbox.gif) |
Thank you for taking the time to complete this important survey.
Please remember to fold it, seal it, and place it in the envelope provided.
Date completed _________________________________
If this survey was not completed by the person named on the front page, who completed the survey?
____________________________________________________________________________________
What is this person’s relationship to the person named on the front page?
____________________________________________________________________________________
____________________________________________________________________________________
What is the reason the person named on the front page did not complete the survey himself/herself?
____________________________________________________________________________________
____________________________________________________________________________________
Data Year 2010
11-230
|