Form Approved
Form Approved
OMB #0935-0118
Expiration Date 11/30/2021
Self 2019
![Medical Expenditure Panel Survey (MEPS)](images/MEPS_Tagline.png)
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 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. 299c-3(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.
![Department of Health and Human Services (HHS) logo](images/DHHS_logo.jpg) |
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.
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.
7. |
Has your diabetes caused problems with your kidneys? |
|
![empty check box](images/empty_checkbox.gif) |
Yes |
|
![empty check box](images/empty_checkbox.gif) |
No |
8. |
Has your diabetes caused problems with your eyes that needed to be treated by an ophthalmologist? |
|
![empty check box](images/empty_checkbox.gif) |
Yes |
|
![empty check box](images/empty_checkbox.gif) |
No |
9. |
Is your diabetes being treated by modifying your diet? |
|
![empty check box](images/empty_checkbox.gif) |
Yes |
|
![empty check box](images/empty_checkbox.gif) |
No |
10. |
Is your diabetes being treated by medications taken by mouth? |
|
![empty check box](images/empty_checkbox.gif) |
Yes |
|
![empty check box](images/empty_checkbox.gif) |
No |
11. |
Is your diabetes being treated with insulin injections? |
|
![empty check box](images/empty_checkbox.gif) |
Yes |
|
![empty check box](images/empty_checkbox.gif) |
No |
Thank you for taking the time to complete this important survey.
Please remember to return it to your interviewer.
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? |
![empty check box](images/empty_checkbox.gif) |
Husband or wife |
![empty check box](images/empty_checkbox.gif) |
Unmarried partner |
![empty check box](images/empty_checkbox.gif) |
Mother, father, or guardian |
![empty check box](images/empty_checkbox.gif) |
Son or daughter |
![empty check box](images/empty_checkbox.gif) |
Other relative |
![empty check box](images/empty_checkbox.gif) |
Not related |
What is the reason the person named on the front page did not complete the survey himself/herself?
Data Year 2018
19-230
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