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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.

Sincerely,
Farah Orap-Silver
farahjane@hotmail.com

The survey is closed as of February 3, 2003.

1. What is your gender?

Male
Female

2. Where do you live?

3. What is your age?

4. What is your ethnicity?

Black/African American
Latino/Hispanic
Asian
White/Caucasian
Native American
Pacific Islander
Other (specify)

5. How does diabetes affect you?

I have diabetes
I take care of someone with diabetes (specify person and age)
Other (specify)

6. Diabetes type:

Type 1
Type 2
Gestational

7. How long have you been affected by diabetes?

Years
Months

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)

Advocacy
Bilingual staff (specify language)
Case management
Child care
Education
Food vouchers
Housing
Medical social work
Mental health
Neuropsychology
Nutritionist
Transportation
Treatment peer advocacy
Other (please list)

10. What service is most important to you?

11. Are you satisfied with the services you currently receive?

Yes
No

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?

Yes
No

14. If yes, please list the services:

15. Do you think people affected by diabetes, including yourself, would benefit from support groups?

Yes
No

16. Please explain why or why not.

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Last Updated: Monday February 03, 2003 08:35:24
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