Form 50 Diabetes Care SAQ

Draft

Form Approved
OMB #0935-0118
Expiration Date 11/30/2023

Self

2023

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:

/
MONTH

/
DAY

YEAR

PID:

RUID:

When you have completed the survey, return it to your interviewer.

This survey is authorized under 42 U.S.C. 299a. Privacy is protected by the Privacy Act and Section 308(d) of the Public Health Service Act [42
U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. The confidentiality of your responses to this survey is protected by Section 944(c). 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 of the
U.S. Department of Health and Human Services

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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.
1. Have you ever been told by a doctor or
other health professional that you have
diabetes or sugar diabetes?
MARK  ONE.

3. Which of the following year(s) did a doctor
or other health professional check your
feet for any sores or irritations?
MARK  ALL THAT APPLY.

Yes  Please continue.

During 2023

No  Thank you for your time.
This survey is complete.

During 2022

2. During 2022, how many times did a doctor,
nurse, or other health professional check
your blood for glycosylated hemoglobin
or "hemoglobin A-one-C"?
(A1C is a blood test to monitor the glucose level of
diabetes over a period of several months. The A1C test
is usually done in a lab, hospital, or doctor's office
although a home kit containing materials for one or two
tests is now available. The A1C test is not the same as
a Home Glucose Monitoring test which is used at home
to monitor glucose levels on a daily or weekly basis,
and needs supplies of disposable test strips.)

During 2021
Before 2021
Never
4. Which of the following year(s) did you have
an eye exam in which your pupils were
dilated? This would have made you
temporarily sensitive to bright light.
MARK  ALL THAT APPLY.
During 2023
During 2022
During 2021

If you had this blood test, fill in
NUMBER OF TIMES

Before 2021
Never

Did not have A1C blood test
Don't know
Never

5. Which of the following year(s) did you
have your blood cholesterol checked?
MARK  ALL THAT APPLY.
During 2023
During 2022
During 2021
Before 2021
Never

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6. Which of the following year(s) did you
get a flu vaccination (shot or nasal spray)?
MARK  ALL THAT APPLY.
During 2023
During 2022
During 2021
Before 2021
Never
7. Has your diabetes caused problems
with your kidneys?
Yes
No

11. Is your diabetes being treated with
insulin injections?
Yes
No
12. During the last 12 months, have you
learned how to take care of your diabetes?
Yes
No  Go to Question 14


13. Which of the following methods have you
used to learn to take care of your diabetes?
MARK  ALL THAT APPLY.
Talking to a doctor/health professional
within your primary care practice

8. Has your diabetes caused problems
with your eyes that needed to be treated
by an ophthalmologist?

Talking to a doctor/health professional
not in your primary care practice
Telephone call with a
health professional
Reading about it on the Internet
Taking a group class
Other (specify)

Yes
No
9. Is your diabetes being treated by
modifying your diet?
Yes
No
10. Is your diabetes being treated by
medications taken by mouth?
Yes
No

14. How confident are you in taking care of
your diabetes?
Not confident at all
Somewhat confident
Confident
Very confident
Refused
Don't know

 PLEASE CONTINUE TO THE BACK COVER.

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Thank you for taking the time to complete this important survey.
Please remember to return it to your interviewer.
Date completed:

MONTH

DAY

YEAR

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?
Husband or wife
Mother, father, or guardian
Other relative
Son or daughter
Not related
Unmarried partner
What is the reason the person named on the front page did not complete the survey himself/herself?

Data Year 2022
23-230

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