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Diabetes Consumer Questionnaire

I am a Social Work graduate student at UCLA and am currently conducting a needs assessment in the area of diabetes in Los Angeles County. Specifically, I am trying to identify the existing services and gaps in services for children and families affected by diabetes. I have already contacted several diabetes service providers and have received important information, but I also realize the importance of learning from those directly affected by diabetes. Your input is greatly appreciated.

Farah Orap-Silver

The survey is closed as of February 3, 2003.

1. What is your gender?

2. Where do you live?
3. What is your age?
4. What is your ethnicity?

5. How does diabetes affect you?

6. Diabetes type:

7. How long have you been affected by diabetes?
8. Where do you go for diabetes-related services (name of agency, hospital, school, etc. and city/state)?
9. What types of services do you currently receive? (check all that apply)

10. What service is most important to you?
11. Are you satisfied with the services you currently receive?

12. If not, please explain how why and how these services can be improved
13. Are there other services that you would like to receive?

14. If yes, please list the services:
15. Do you think people affected by diabetes, including yourself, would benefit from support groups?

16. Please explain why or why not.

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Last Updated: Monday February 03, 2003 09:35:24
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