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Form Approved
OMB #0935-0118
Exp. Date 12/31/2018
Proxy 2017
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 by |
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. 299-c3(
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.
 |
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 checking 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.
1. |
Has (NAME) ever been told by a doctor or other health professional that he/she has diabetes or sugar diabetes? (CHECK ONE) |
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Yes Please continue. |
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No Thank you for your time. This survey is complete. |
7. |
Has (NAME)’s diabetes caused problems with his/her kidneys? |
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Yes |
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No |
8. |
Has (NAME)’s diabetes caused problems with his/her eyes that needed to be treated by an ophthalmologist? |
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Yes |
| |
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No |
9. |
Is (NAME)’s diabetes being treated by modifying his/her diet? |
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Yes |
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No |
10. |
Is (NAME)’s diabetes being treated by medications taken by mouth? |
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Yes |
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No |
11. |
Is (NAME)’s diabetes being treated with insulin injections? |
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Yes |
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No |
12. |
During the last 12 months, has (NAME) learned how to take care of his/her diabetes? |
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Yes |
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No Go to Question 14 |
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?
____________________________________________________________________________________
What is the reason the person named on the front page did not complete the survey himself/herself?
____________________________________________________________________________________
Data Year 2016
17-231
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