Form Approved
OMB #0935-0118
Expiration Date 11/30/2021
Proxy 2019
![Medical Expenditure Panel Survey (MEPS)](images/MEPS_Tagline.png)
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, return it to your interviewer.
This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42
U.S.C. 299c–3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. 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, 5600 Fishers Lane Room #07W42, Rockville, MD 20857.
![Department of Health and Human Services (HHS) 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 marking 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.
7. |
Has (NAME)’s diabetes caused problems with his/her kidneys? |
|
![empty check box](images/empty_checkbox.gif) |
Yes |
|
![empty check box](images/empty_checkbox.gif) |
No |
8. |
Has (NAME)’s diabetes caused problems with his/her eyes that needed to be treated by an ophthalmologist? |
|
![empty check box](images/empty_checkbox.gif) |
Yes |
|
![empty check box](images/empty_checkbox.gif) |
No |
9. |
Is (NAME)’s diabetes being treated by modifying his/her diet? |
|
![empty check box](images/empty_checkbox.gif) |
Yes |
|
![empty check box](images/empty_checkbox.gif) |
No |
10. |
Is (NAME)’s diabetes being treated by medications taken by mouth? |
|
![empty check box](images/empty_checkbox.gif) |
Yes |
|
![empty check box](images/empty_checkbox.gif) |
No |
11. |
Is (NAME)’s diabetes being treated with insulin injections? |
|
![empty check box](images/empty_checkbox.gif) |
Yes |
|
![empty check box](images/empty_checkbox.gif) |
No |
Thank you for taking the time to complete this important survey.
Please remember to return it to your interviewer.
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? |
![empty check box](images/empty_checkbox.gif) |
Husband or wife |
![empty check box](images/empty_checkbox.gif) |
Unmarried partner |
![empty check box](images/empty_checkbox.gif) |
Mother, father, or guardian |
![empty check box](images/empty_checkbox.gif) |
Son or daughter |
![empty check box](images/empty_checkbox.gif) |
Other relative |
![empty check box](images/empty_checkbox.gif) |
Not related |
What is the reason the person named on the front page did not complete the survey himself/herself?
Data Year 2018
19-231
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