0917-0036 Diabetes Survey

Form Approved

OMB Form No. 0917-0036

Expiration Date:

Diabetes Health Coach Survey Date: ______________

Gender: Age: Healthy Heart Participant?

___ Male ___ less than 18 years ___ 35-64 years Yes No

___ Female ___ 18-34 years ___ 65 years and older

Please rate the following statements using numbers 1-5 based on this scale: Circle your answer.

For each statement below circle the number based on this scale:

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

1. I would recommend this clinic to my family and friends 1 2 3 4 5

2. Usually, my health is good. 1 2 3 4 5

3. I am sure I can take care of my own health. 1 2 3 4 5

4. The Diabetes Health Coach clearly answered my questions today. 1 2 3 4 5

5. It is important for me to have a follow-up call from the 1 2 3 4 5

Diabetes Health Coach.

6. The Diabetes Health Coach and I made a goal or plan to improve my health 1 2 3 4 5

(such as blood sugar, blood pressure, exercise, eating, etc.).

7. After today’s Diabetes Health Coach visit, I can manage diabetes better. 1 2 3 4 5

What did you like about your visit with the Diabetes Health Coach?

______________________________________________________________________________

What can the Diabetes Health Coach do better?

______________________________________________________________________________

Diabetes Health Coach (circle one): Ivan Farrah Shanna Phillip Matthew Craig

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The   valid OMB control number for this information collection is 0917-0036.  The time required to complete this information collection is estimated to average 3 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer.

Date Modified: January 21, 2021