Form Approved
OMB #0935-0118
Exp. Date 01/31/2013
Proxy 2011
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 this 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.
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 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.
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 |
|
|
No |
|
8. |
Has (NAME)’s diabetes caused problems with his/her eyes that needed to be treated by an ophthalmologist? |
|
Yes |
|
|
No |
|
9. |
Is (NAME)’s diabetes being treated by modifying his/her diet? |
|
Yes |
|
|
No |
|
10. |
Is (NAME)’s diabetes being treated by medications taken by mouth? |
|
Yes |
|
|
No |
|
11. |
Is (NAME)’s diabetes being treated with insulin injections? |
|
Yes |
|
|
No |
|
12. |
During the last 12 months, has (NAME) learned how to take care of his/her diabetes? |
|
Yes |
|
|
No (skip Q 14) |
|
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 2010
11-231
|