Proxy 2008
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.
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 this label, and place it in the envelope provided.
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. In the questions below, “(NAME)” refers to the person listed in the box on the front page.
1. |
Has (NAME) ever been told by a doctor or
other health professional that he/she has diabetes or sugar
diabetes? (CHECK ONE) |
|
Yes |
1 |
Please continue. |
|
No |
2 |
Thank you for your time.
This survey is complete. |
3. |
During 2007, how many times did a health professional check (NAME)’s feet for any sores or irritations? (FILL IN NUMBER OF TIMES) |
|
Number of Times |
_____ |
|
Never |
00 |
5. |
Has (NAME)’s diabetes caused problems with his/her kidneys? |
|
Yes |
1 |
|
No |
2 |
6. |
Has (NAME)’s diabetes caused problems with his/her eyes that needed to be treated by an ophthalmologist? |
|
Yes |
1 |
|
No |
2 |
7. |
Is (NAME)’s diabetes being treated by modifying his/her diet? |
|
Yes |
1 |
|
No |
2 |
8. |
Is (NAME)’s diabetes being treated by medications taken by mouth? |
|
Yes |
1 |
|
No |
2 |
9. |
Is (NAME)’s diabetes being treated with insulin injections? |
|
Yes |
1 |
|
No |
2 |
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 complete _________________________________
Who completed the survey for the person named on the front page?
____________________________________________________________________________________
What is your relationship to the person named on the front page?
____________________________________________________________________________________
____________________________________________________________________________________
This survey is part of the Medical Expenditure Panel Survey, conducted by the U.S. Department of Health and Human Services. This survey
is authorized under Section 902(a) of the Public Health Service Act [42 U.S.C. 299a]. The confidentiality of personal information is protected
by Federal Statutes, Section 924(c) and Section 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 242m(d)]. This law prohibits
release of personal information outside the public health agencies sponsoring the survey or their contractors without first obtaining
permission from the person who gave the information. The Federal government requires that all persons asked to respond to one of its
surveys be given the following information: Public reporting burden for this collection of information is estimated to average
5 minutes
per interview, the estimated time required to complete the “A Survey About Your Diabetes Care.” Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:
Reports Clearance Officer
Attention: PRA, United States
Public Health Service
Paperwork Reduction Project (0935-0098)
Hubert H. Humphrey Building, Room 721-B
200 Independence Avenue, SW
Washington, DC 20201 |