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SDPI Diabetes Prevention Program Participant Baseline

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					 SDPI Healthy Heart Project                                                        Family Annual Questionnaire
                                                                                                       A3.H.03
                                                                                                               Page 1 of 4

                                                             Completed by adult family member who previously
                                                       completed the Family Baseline Questionnaire (if possible)



 THIS BOX COMPLETED BY: (Initials) ___________________                              __ __ - __ __ - 200 __
                                                                                      Date Form Completed

 __ __ __ __ __                __         F __ __ __ __
 NDPID Grantee #              Site #       Family Member of Participant ID #
                                          (Use the same ID # as the Participant)



Project staff: Before continuing please check that all information in the box above is complete.




Greetings!

Thank you for participating, along with your family member, in the SDPI Healthy Heart Project. In the pages that follow,
you will find questions that ask how you feel about the project. We are asking you these questions because we want to
figure out what helps people succeed in the project.

We have set this up so it will take most people about 15 minutes to answer all the questions. Some of the answers may
not match exactly how you would answer the questions. When this happens, please choose the answer that is closest to
how you feel, think, act, or what you know. This is not a test. Just answer as best you can.

Answering these questions is completely voluntary. If there are questions you do not want to answer, you can skip
them. Also, your answers will be confidential. After you complete the survey, please return it to the project staff member.

If you have any questions, please ask the project staff member for help. He or she will be glad to help you.

Thank you for helping us make the project better. We greatly appreciate your time!




Data_core\Manual+Forms CURRENT\f2d7d817-7aff-451c-b058-e1599631bd28.doc
Last Revised: 3/23/2010 6:34 AM
 SDPI Healthy Heart Project                                                           Family Annual Questionnaire
                                                                                                          A3.H.03
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About the Project

The following questions ask for your impressions about your family member’s participation in community activities related
to living a healthy life.

 1. Over the last 12 months, how many times did your family member attend community activities or
                                                                                                                                   ___ ___ times
    events with a focus on healthy eating? ……………………………………………………………………...

 2. Over the last 12 months, how many times did your family member attend community activities or
                                                                                                                                   ___ ___ times
    events with a focus on physical activity? ……………………………………………………………………

 3. Over the last 12 months, how many times did your family member attend community activities or
                                                                                                                                   ___ ___ times
    events with a focus on getting regular health care screening? …………………………………………...


4. The next questions ask for your opinions about the SDPI Healthy Heart Project.

                                                                                                                 Neither
                                                                                             Strongly                                   Strongly
                                                                                                        Agree   Agree nor   Disagree
                                                                                              Agree                                     Disagree
                                                                                                                Disagree

 a. This project was good for my family member ………………………………………..….…                            ○         ○         ○           ○           ○
 b. I was willing to change my behavior to make this project work for my family
    member …………………………………………………………………………………….…..                                                ○         ○         ○           ○           ○
 c. A lot of time was needed to take part in this project …………………………..….……….                   ○         ○         ○           ○           ○
 d. I understood what my family member needed to do in this project ………..….…………                ○         ○         ○           ○           ○
 e. Those living in our home did a lot to make this project easier for my family member .…     ○         ○         ○           ○           ○
 f. The changes we made due to this project were good for the entire family …….…….....         ○         ○         ○           ○           ○
 g. Each family member is responsible for his or her own health …………………….……...                 ○         ○         ○           ○           ○
 h. My family had too many other problems to focus on this project ……….………….….....             ○         ○         ○           ○           ○
 i.   From what I’ve seen, my community supports this project ………….……….……………                   ○         ○         ○           ○           ○
 j.   Things happened in our family that made it hard for my family member to follow the
      project …………………….……………………………………………………………...……..                                          ○         ○         ○           ○           ○
 k. The family changed their habits to make it easier to meet project goals ..…….…...……        ○         ○         ○           ○           ○
 l.   I trust those helping my family member in this project ………….……………….…...……                ○         ○         ○           ○           ○
 m. We understood what changes were needed for my family member to follow the
    project …………………………………………………………………………………….…….                                               ○         ○         ○           ○           ○
 n. It was hard to stick to the changes suggested by the project ……………….…………....               ○         ○         ○           ○           ○
 o. I felt like we could ask all the questions we wanted to ask…………………….….……….                 ○         ○         ○           ○           ○
 p. The project staff involved family members in project activities………….………….……..              ○         ○         ○           ○           ○
 q. Finding time for everything was hard………………………………………….……………..                               ○         ○         ○           ○           ○
 r. Family members resented the changes needed for the project……….…………….…....                  ○         ○         ○           ○           ○

Data_core\Manual+Forms CURRENT\f2d7d817-7aff-451c-b058-e1599631bd28.doc
Last Revised: 3/23/2010 6:34 AM
 SDPI Healthy Heart Project                                                               Family Annual Questionnaire
                                                                                                              A3.H.03
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                                                                                                                     Neither
                                                                                                 Strongly                                  Strongly
                                                                                                            Agree   Agree nor   Disagree
                                                                                                  Agree                                    Disagree
                                                                                                                    Disagree

 s. I encouraged my family member to participate in project activities………….….……...…                ○         ○         ○           ○          ○
 t. There is too much paperwork in the project …………………………….…………………..                               ○         ○         ○           ○          ○
 u. The project activities are at convenient times ……………………...................................     ○         ○         ○           ○          ○
 v. My family member had trouble finding transportation to project activities ……………...             ○         ○         ○           ○          ○
 w. I had to push my family member to continue in the project …………….…………..…….                      ○         ○         ○           ○          ○
 x. The project was too hard to do…………………………………………….………………….                                       ○         ○         ○           ○          ○
 y. I needed to know more about the project to help my family member….…………...…….                   ○         ○         ○           ○          ○
 z. As a result of the project, my family member has made changes to his or her diet…….            ○         ○         ○           ○          ○
 aa. As a result of the project, my family member changed how he or she exercised…….…              ○         ○         ○           ○          ○
 ab. As a result of the project, my family member is better at taking medications as
    prescribed by the doctor to improve his or her health ………………………………………                          ○         ○         ○           ○          ○
 ac. It was hard to keep to the new “good” habits …………..…..                                        ○         ○         ○           ○          ○
 ad. We continued to keep track of our progress towards the project goals ourselves …...…          ○         ○         ○           ○          ○
 ae. Everyone went back to doing their own thing ……………………………………………….                               ○         ○         ○           ○          ○
 af. It was hard to remember all the details of the project ……………………….…………...…                     ○         ○         ○           ○          ○
 ag. The whole family did what they could to make sure we didn’t slip back to old habits ….        ○         ○         ○           ○          ○
 ah. We looked for other goals that would help in healthy living ……………………………….                     ○         ○         ○           ○          ○


5. Do you have any other thoughts about or reactions to the project that you care to share?

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________



About You
We would like to confirm or update the information we gathered from you when your family member began the SDPI
Healthy Heart Project.

6. Did you fill out these questions (the Family Baseline Questionnaire) when the project started?

      ○ Yes                  ○ No


Data_core\Manual+Forms CURRENT\f2d7d817-7aff-451c-b058-e1599631bd28.doc
Last Revised: 3/23/2010 6:34 AM
 SDPI Healthy Heart Project                                                               Family Annual Questionnaire
                                                                                                              A3.H.03
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7. What is your relationship to the person participating in the project?

      ○   Married to him or her or living together as if married
      ○   Parent
      ○   Sister or brother
      ○   Child or grandchild
      ○   Grandparent
      ○   Other relative
      ○   Friend
      ○   Other, please describe: __________________________


8 . Are you also a participant in the Healthy Heart Project?

      ○   Yes, currently a participant
      ○   I was a participant in the past
      ○   I hope to be a participant in the future
      ○   No, I am not a participant


9. What is your age today? …………. __ __ __ years old


10. Are you:         ○ Male                    ○ Female

11. What is the highest grade in school you completed?

      ○ None                  ○ 6 th grade           ○ 12th grade                     ○ 1 year of vocational school
      ○ 1st grade             ○ 7 th grade           ○ 1 year of college              ○ 2 years of vocational school
      ○ 2nd grade             ○ 8 th grade           ○ 2 years of college             ○ 3 years of vocational school
      ○ 3rd grade             ○ 9 th grade           ○ 3 years of college             ○ 4 or more years of vocational school
      ○ 4 th grade            ○ 10th grade           ○ 4 years of college
      ○ 5 th grade            ○ 11th grade           ○ Graduate/Professional

12. If you didn’t graduate high school, did you complete your GED?

      ○ Yes                     ○ No                 ○ I graduated from high school

13. Are you (choose the one that best describes you):

      ○   Working full-time now        ○    Going to school
      ○   Working part-time now        ○    Disabled (unable to work)
      ○   Unemployed now               ○    Never worked for pay
      ○   Retired                      ○    Seasonal job

Thank you! Please return the survey to the project staff member.
Data_core\Manual+Forms CURRENT\f2d7d817-7aff-451c-b058-e1599631bd28.doc
Last Revised: 3/23/2010 6:34 AM

				
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