Registration and Pre-Survey

Delaware Self-Management Program

As part of this program, we are asked to collect information about participants to see the effectiveness of the programs and ways we can improve our offerings. Most of the data is kept internally as per privacy laws. We send program information to the National Council on Aging (NCOA) for comparison with other like programs. The collected data will be used to determine if we are providing the most appropriate education to you and are able to change some of your health outcomes. We will collect this data at various time periods after this six-week program has ended through an online survey.

You are invited to participate in this online survey collected by the Delaware Self-Management Program (SMP). Agreeing to respond to the survey is completely voluntary and does not impact future participation in any SMP programming. Your responses will not be shared with anyone outside of the program, and your identity will be protected.

Thank you!

Registration

Please enter the following information to register

Please list your email or a family member/friend’s email who will receive emails for you. If there is no email or the participant is unable to participate in post surveys, please leave blank.

Phone
How did you hear about this class?*

Select the most appropriate reason you decided to register

Did your doctor or other health care provider suggest that you attend this program?*

Delaware Self-Management Program Pre-Survey

Please fill out the following information.

__ years

Are you:*

Please specify

Which of the following best represents how you think of yourself?*

Select one

Ethnicity*

What is your race? Please select all that apply

Do you have a disability?*
Are you deaf or do you have difficulty hearing?*
Are you blind or do you have serious difficulty seeing, even when wearing glasses?*
Do you live alone?*
What is the highest grade or year of school you completed?*
Have you ever served in the military?*
During the past year, did you provide regular care or assistance to a friend or family member who has a long-term health problem or disability?*
In general, would you say that your health is:*

Has a health care provider ever told you that you have any of the following chronic conditions? Please select all that apply, or check None if you have never been told you had one of these chronic conditions.

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?*
Do you have serious difficulty concentrating, remembering, or making decisions?*
Do you have a serious difficulty walking or climbing stairs?*
Do you have difficulty dressing or bathing?*
How often do you feel lonely?*
How often do you feel isolated from those around you?*
How sure are you that you can manage your condition so you can do the things you need and want to do?*

(1 - Totally unsure, 10 - Totally sure)

What is your primary language?*
What is your primary health care insurance?*
Smoking (check one)*
Physical activity*

Do you do any type of physical activity (for example: walking, strengthening exercises, swimming, bicycling, aerobic exercise)?

Little interest or pleasure in doing things?*

In the last two weeks, how often have you been bothered?

Feeling down, depressed or hopeless?*

In the last two weeks, how often have you been bothered?

Have you visited either in the last month?*
Pain level*

(0 - no pain, 10 - worst pain)

Powered by Smartsheet Modern Logo On Light
Privacy Notice|Report Abuse