Power to Prevent - National Diabetes Education Program - National ...

Pre-Program Questionnaire - Demographics
(Optional Pre-Session 1 Demographics Questionnaire)
Name or other identifer (such as initials with day and month of birth): ______________________
How did you fnd out about the program?
Please check all of the following that apply.
Neighbors
Church members
Family members
Flyers
Posters
Newsletter
Newspaper
Radio
Doctor or clinic
Other:_________________________________________________________________________
General Information
. What is your sex?
Male Female
2.What is your race: (Check all that apply.)
Black or African American
American Indian or Alaska Native
White or Caucasian
Asian
Native Hawaiian or other Pacifc Islander
Other: ___________________________
3. Are you of Latino or Hispanic ethnicity?
Yes No Don’t know
4. What is your date of birth (month/day/year): _______ / _______ / _______
Please put your name (or your initials with day and month of birth) on this questionnaire
and give it to your program leader.
NDEP Power to Prevent Appendices 43