Form Approved
OMB #0935-0118
Exp. Date 01/31/2016
Proxy 2013
Medical Expenditure Panel Survey (MEPS)
A Survey About Diabetes Care
The care of people with diabetes is an important concern of the U.S. Department
of Health and Human Services. We would appreciate it if you would take a few
minutes to answer the following questions on the care your family member received
for his or her diabetes. Your participation is voluntary and all of the 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 for |
NAME: ________________________
_______________________________
DOB: |
__________ |
PID: |
__________ |
RUID: |
_________________________ |
|
When you have completed the survey, please fold it, seal it with the 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.
![Department of Health and Human Services (DHHS) logo](images/DHHS_logo.jpg) |
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 |
A Survey About Diabetes Care
Instructions: Answer each question by checking one box or filling in a number when
necessary. If you are unsure about how to answer a question, please give the best
answer you can. In the questions below, “(NAME)” refers to the person listed in the
box on the front page.
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. |
Has (NAME) ever been told by a doctor or
other health professional that he/she has
diabetes or sugar diabetes? (CHECK ONE) |
|
Yes |
Please continue. |
|
No |
Thank you for your time. This survey is complete. |
7. |
Has (NAME)’s diabetes caused problems with his/her kidneys? |
|
Yes |
![empty check box](images/empty_checkbox.gif) |
|
No |
![empty check box](images/empty_checkbox.gif) |
8. |
Has (NAME)’s diabetes caused problems with his/her 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 (NAME)’s diabetes being treated by modifying his/her diet? |
|
Yes |
![empty check box](images/empty_checkbox.gif) |
|
No |
![empty check box](images/empty_checkbox.gif) |
10. |
Is (NAME)’s 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 (NAME)’s 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, has (NAME) learned how to take care of his/her diabetes? |
|
Yes |
![empty check box](images/empty_checkbox.gif) |
|
No (skip to 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 _________________________________
Who completed the survey for the person named on the front page?
____________________________________________________________________________________
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 2012
12-231
|