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What is your age?
 
15-24
 
25-34
 
35-44
 
45-54
 
55-64
 
65+
 
 
 
Race/Ethnicity?
 
Hispanic or Latino
 
American Indian or Alaska Native
 
Asian
 
African American
 
Native Hawaiian or Other Pacific Islander
 
White
 
Other
 
 
 
Do you have diabetes?
 
Weekly
 
Monthly
 
Quarterly
 
Annually
 
Other
 
 
 
 
Do you have the information, support & tools you need to manage diabetes?
 
Weekly
 
Monthly
 
Quarterly
 
Annually
 
Other
 
 
 
 
Have you ever had diabetes education?
 
Completely disagree
 
Somewhat disagree
 
Slightly disagree
 
Neutral, Slightly agree
 
Somewhat agree
 
Completely agree
 
 
 
Would you consider going to diabetes education classes?
 
Completely disagree
 
Somewhat disagree
 
Neutral
 
Somewhat agree
 
Completely agree
 
Other
 
 
 
 
What would keep you from going to diabetes education classes?
 
Weekly
 
Monthly
 
Quarterly
 
Annually
 
Other
 
 
 
 
Do you think diabetes education classes should be a one time class or should you attend refreshers??
 
1
 
2
 
3
 
4
 
5
 
6
 
7
 
 
 
What do you think would be needed in a diabetes education program to make it ideal for you??
 
A very great deal
 
A great deal
 
Quite a bit
 
Moderately
 
Somewhat
 
A little bit
 
A tiny bit
 
About the same
 
Other
 
 
 
 
Where do you get answers to your questions about diabetes?
 
Not at all satisfied
 
Slightly satisfied
 
Moderately satisfied
 
Very satisfied
 
Completely satisfied
 
Other
 
 
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