Self 2009
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. 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.
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 # 0935-0104
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 |
1 |
Please continue. |
|
No |
2 |
Thank you for your time.
This survey is complete. |
7. |
Has your diabetes caused problems with your kidneys? |
|
Yes |
1 |
|
No |
2 |
8. |
Has your diabetes caused problems with your eyes that needed to be treated by an ophthalmologist? |
|
Yes |
1 |
|
No |
2 |
9. |
Is your diabetes being treated by modifying your diet? |
|
Yes |
1 |
|
No |
2 |
10. |
Is your diabetes being treated by medications taken by mouth? |
|
Yes |
1 |
|
No |
2 |
11. |
Is your diabetes being treated with insulin injections? |
|
Yes |
1 |
|
No |
2 |
12. |
During the last 12 months, have you learned how to take care of your diabetes? |
|
Yes |
1 |
|
No
(skip Q 13) |
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 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?
____________________________________________________________________________________
____________________________________________________________________________________
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
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