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DPP Enrollment Survey June 2022

Diabetes Prevention Program Enrollment Survey

Welcome! Please complete this enrollment form for the Diabetes Prevention Program. This program will be held virtually via Zoom. The group will meet weekly on Mondays from 1-2PM beginning on June 6. Throughout the year, the meetings will lessen to twice a month and then monthly.

The Diabetes Prevention Program is funded by the State of Nevada/the Centers for Disease Control and Prevention. We ask that you provide information to ensure you are eligible for the program and to evaluate the effectiveness of the program. If you wish to leave a question blank, you may. The page will refresh and warn you that a question was not completed. Simply click 'Next' again and you will be taken to the next page in the survey. All data is encrypted and stored securely.

Name *This question is required.

Last
First

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

Mailing Address *This question is required.

Address
City
Zipcode

1. Did your doctor or other health care provider suggest you attend this program?

Yes, a doctor or doctor's office	Yes, a pharmacist	Yes, other healthcare professional (ie. dietician)	No
Yes, a doctor or doctor's office	Yes, a pharmacist	Yes, other healthcare professional (ie. dietician)	No

2. Which of the following best describes the main source of your motivation for enrolling in the program?

3. What is your sex?

4. What is your gender?

5. Are you of Hispanic or Latino origin?

6. What is your race / ethnicity?

American Indian or Alaskan Native
Asian or Asian American
Black or African American

Native Hawaiian or other Pacific Islander
White

7. What is the highest education level you completed?

Less than grade 12 (no high school diploma or GED)	High school graduate or GED	Some college or technical school	College or technical school graduate or higher
Less than grade 12 (no high school diploma or GED)	High school graduate or GED	Some college or technical school	College or technical school graduate or higher

8. Please indicate if a healthcare provider has ever told you that you have any of the following chronic conditions:

Schizophrenia or other Psychotic Disorder
Stroke
Arthritis / Rheumatic Disease
Other Chronic Condition

9. What is your health insurance coverage?

Please enter an 'other' value for this selection.

10. Do you understand that this is a 12 month lifestyle change program, with weekly meeting for 6 month and bi-weekly meeting for another 6 months?
(This program is provided at no cost to participants) *This question is required.

Please continue to the next page and complete eligibility information.