63032
Form Approved
OMB# 0935-0118
Exp. Date 11/30/2023
Proxy 2022
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 for
NAME:
DOB: MONTH: DAY: YEAR:
RUID: PID:
When you have completed the survey, return it to your interviewer.
This survey is authorized under 42 U.S.C. 299a. Privacy is protected by the Privacy Act and Section 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. The confidentiality of your responses to this survey is protected by Section 944(c). 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 7 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.
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 Your 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.
Has (NAME) ever been told by a doctor or other health professional that he/she hasdiabetes or sugar diabetes?
MARK ONE.
Yes, Please continue.
No, Thank you for your time. This survey is complete.
During 2021, how many times did a doctor, nurse, or other health professional check (NAME)'s blood for glycosylated hemoglobin or "hemoglobin A-one-C"?
(A1C is a blood test to monitor the glucose level of diabetes over a period of several months. The A1C test is usually done in a lab, hospital, or doctor's office although a home kit containing materials for one or two tests is now available. The A1C test is not the same as a Home Glucose Monitoring test which is used at home to monitor glucose levels on a daily or weekly basis, and needs supplies of disposable test strips.)
If (NAME) you had this blood test, fill in NUMBER OF TIMES
Did not have A1C blood test
Don't know
Never
Which of the following year(s) did a doctor or other health professional check (NAME)'s feet for any sores or irritations?
MARK ALL THAT APPLY.
During 2022
During 2021
During 2020
Before 2020
Never
Which of the following year(s) did (NAME) have an eye exam in which his/her pupils were dilated? This would have made (NAME) temporarily sensitive to bright light.
MARK ALL THAT APPLY.
During 2022
During 2021
During 2020
Before 2020
Never
Which of the following year(s) did (NAME) have his/her blood cholesterol checked?
MARK ALL THAT APPLY.
During 2022
During 2021
During 2020
Before 2020
Never
Which of the following year(s) did (NAME) get a flu vaccination (shot or nasal spray)?
MARK ALL THAT APPLY.
During 2022
During 2021
During 2020
Before 2020
Never
Has (NAME)'s diabetes caused problems with his/her kidneys?
Yes
No
Has (NAME)'s diabetes caused problems with his/her eyes that needed to be treated by an ophthalmologist?
Yes
No
Is (NAME)'s diabetes being treated by modifying his/her diet?
Yes
No
Is (NAME)'s diabetes being treated by medications taken by mouth?
Yes
No
Is (NAME)'s diabetes being treated with insulin injections?
Yes
No
During the last 12 months, has (NAME) learned how to take care of his/her diabetes?
Yes Go to Next Question
No Go to Question 14
Which of the following methods has (NAME) used to learn to take care of his/her diabetes?
MARK ALL THAT APPLY.
Talking to a doctor/health professional within his/her primary care practice
Talking to a doctor/health professional not in his/her primary care practice
Telephone call with a health professional
Reading about it on the Internet
Taking a group class
Other (specify)
How confident is (NAME) in taking care of his/her diabetes?
Not confident at all
Somewhat confident
Confident
Very confident
Refused
Don't know
Thank you for taking the time to complete this important survey.
Please remember to return it to your interviewer.
Date completed:
Month: Day: Year:
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?
Husband or wife
Unmarried partner
Mother, father, or guardian
Son or daughter
Other relative
Not related
What is the reason the person named on the front page did not complete the survey himself/herself?
Data Year 2021
22-231