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ABOUT
–
OUR LEADERSHIP
OUR STORY
JOIN OUR TEAM
E-NEWSLETTER
–
PHOTO GALLERY
ANNUAL REPORT
LOCATIONS
CONTACT US
PROGRAMS
–
REFER A CLIENT
DIABETES SERVICES
DIABETES DAYTON
CANCER SERVICES
MEALS-ON-WHEELS
SENIOR FARMERS MARKET
WELLNESS SERVICES
–
CARRIE’S CAFE & SENIOR DINING CENTERS
HELP-AT-HOME
PERSONAL EMPOWERMENT SERVICES
HIV/AIDS NUTRITIONAL SUPPORT
SENIOR PET CARE
VISITING NURSES
SUPPORT
–
DONATE
PLANNED GIVING
LEGACY ENDOWMENT CAMPAIGN
ENDOWMENT RESOURCE DIRECTORY
LIFECARE ALLIANCE STORE
–
SHOPPING REWARDS
Cancer Thrift Shops
SOCIAL ENTERPRISE
VOLUNTEER
VOLUNTEER APPLICATION
Blog
Referrals
Volunteer
Give Now
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Community Member Survey
Step
1
of
4
25%
Introduction
The information collected from this survey will be used to help us improve CODA programming and engage better with the diabetes community in central Ohio. It will also provide us with information needed to gain additional funding for future opportunities.
Demographic Information
ZIP code
*
In what county does the affected person primarily reside?
*
What is the ZIP code of the affected person's primary residence?
*
What is the affected person's gender identity?
*
Choose One
Male
Female
Nonbinary
Prefer Not to Say
What is the ethnicity of the affected person?
*
Choose One
African American
Bi/multi-racial
Caucasian
Hispanic
Other
What is the approximate income of the affected person's family?
*
Choose One
Less than $20,000
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
Over $100,000
Who is the primary caregiver for the affected person?
*
Choose One
Self
Parent
Grandparent
Spouse (if over 18)
Other family member
Friend
What is the age of the affected person?
*
Choose One
5-7
8-10
11-13
14-16
17-18
19-25
26-30
31-40
41-50
51-60
60+
What is your role in relation to the diabetes community?
*
Choose One
Patient
Caregiver
Unaffected volunteer
Does the affected person consistently see an endocrinologist?
*
Yes
No
Does the affected person have a primary care physician?
*
Yes
No
Survey Questions
The following information is used to help us plan educational opportunities. Please answer honestly using a scale 1-5 to rate the affected person status. 1=poor 2 3= average 4 5= excellent
Monitoring blood glucose
*
Please enter a number from
1
to
5
.
Properly disposes testing and insulin supplies
*
Please enter a number from
1
to
5
.
Selecting and rotating injection/pump sites
*
Please enter a number from
1
to
5
.
Recognizing signs and symptoms of low blood glucose
*
Please enter a number from
1
to
5
.
Treating low blood glucose
*
Please enter a number from
1
to
5
.
Recognizing symptoms of high blood glucose
*
Please enter a number from
1
to
5
.
Monitoring ketones
*
Please enter a number from
1
to
5
.
Understanding A1C
*
Please enter a number from
1
to
5
.
Decreasing risks for developing chronic complications
*
Please enter a number from
1
to
5
.
Foot care
*
Please enter a number from
1
to
5
.
Adjusting insulin doses
*
Please enter a number from
1
to
5
.
Counting carbohydrates
*
Please enter a number from
1
to
5
.
Incorporating physical activity
*
Please enter a number from
1
to
5
.
Overall adherence to self-care plan
*
Please enter a number from
1
to
5
.
Attitude towards diabetes
*
Please enter a number from
1
to
5
.
Level of confidence/self-esteem
*
Please enter a number from
1
to
5
.
Willingness to discuss their diabetes
*
Please enter a number from
1
to
5
.
Does the participant pump?
*
Choose One
Yes
No
Preparing pump supplies
*
Please enter a number from
1
to
5
.
Changing pump site
*
Please enter a number from
1
to
5
.
Basic pump programming
*
Please enter a number from
1
to
5
.
Setting temporary basal rates
*
Please enter a number from
1
to
5
.
Suspending pump
*
Please enter a number from
1
to
5
.
Survey Questions
What is the affected person's attitude toward diabetes?
*
The Central Ohio Diabetes Association offers programs for youths throughout the year. What type of additional programs would you like to see offered for youths? Please state best day, time and location (i.e. name of village, town or city).
*
The Central Ohio Diabetes Association offers programs for families throughout the year. What type of additional programs would you like to see Central Ohio Diabetes Association offer for families? Please state best day, time and location (i.e. name of village, town or city).
*
Any other comments/suggestions?
*
The CODA Experience
What do you believe is the purpose of CODA?
*
What types of programs would the affected person want to experience?
*
What programs would you like provided for you as a caregiver?
*
What programs would you like provided for you as a caregiver?
*
What would you like to see occur at these programs?
*
What is the best way for CODA to communicate with you?
*
Email
Text
Social Media
Phone Call
Physical Mail
How often do you feel CODA should communicate with you?
*
Once a week
Monthly
Bi-monthly
Quarterly
How often would you like to see programs/services offered by CODA?
*
Monthly
Bi-monthly
Quarterly
How far would you be willing to travel to take the affected person to a program?
*
Less than 15 miles
15 miles
30 miles
45 miles
50+ miles
Keeping in mind the current state of the health pandemic, what is your preferred means of engagement until the pandemic is more resolved?
*
Choose all that apply
In person
Webinars (which are presented & recorded)
Zoom calls (for everyone to see and speak with each other)
Facebook/ Instagram/ Youtube live
A combination of the above
Other
If there was no pandemic to worry about about, what would be your preferred means of engagement?
*
Choose all that apply
In person
Webinars (which are presented & recorded)
Zoom calls (for everyone to see and speak with each other)
Facebook/ Instagram/ Youtube live
A combination of the above
Other
How far would you be willing to travel for yourself to attend a program?
*
Less than 15 miles
15 miles
30 miles
45 miles
50+ miles
What time of the day?
*
Morning
Afternoon
Evening
How long would you be willing to spend at a program?
*
1 hour
2 hours
3 hours
Multiple days
What obstacles would prevent you and/ or the affected person from attending a CODA program/ event? (ex. Transportation, funding, childcare, distance, scheduling, etc)
*
What type of events are you looking to attend?
*
Choose all that apply
Networking
Education
Hangouts
Child
Adult
Would you need transportation assistance?
*
Yes
No
What type of programs/ services would you like to see CODA providing in the future?
*
Do you have any additional feedback for CODA staff?
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