American Diabetes Association: Survey

*

Question - Required - ERP Service ID#

Question - Not Required - Is your program service using Chronicle Diabetes?

Change in Quality Coordinator

(ERP must be informed within 30 days of the coordinator change)

Question - Not Required - Name of Coordinator who is leaving position:

Question - Not Required - New Coordinator (please include name, credentials and title):

Question - Not Required - New Coordinator's Email:

Question - Not Required - New Coordinator's Phone:

Question - Not Required - New Coordinator's FAX:

*

Question - Required - New Coordinator's Address

Question - Not Required - New Coordinator's Address 2

*

Question - Required - New Coordinator's City

*

Question - Required - New Coordinator's State

*

Question - Required - New Coordinator's Zip Code

Question - Not Required - Date Coordinator left position:

Month

Day

Year

Question - Not Required - Date new Coordinator assumed duties:

Month

Day

Year

Question - Not Required - If there is a break in the above dates, please tell us who served as interim coordinator:

Change in Coordinator Email Address

Question - Not Required - Old Coordinator Email Address:

Question - Not Required - New Coordinator Email Address:

Change of Address or Phone Number

Question - Not Required - Site Name:

Question - Not Required - Old Address:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - New Address:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Old Phone #:

Question - Not Required - New Phone #:

Question - Not Required - Old Fax #:

Question - Not Required - NewFax #:

Name Change

Question - Not Required - Address:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Old Site Name:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - New Site Name:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Old Sponsor Name:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - New Sponsor Name:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Please choose one of the following:

This is a name change only. There is no change in the program or the staff.

There has been a substantive change in the program such as a site moves to another sponsor or changes in sponsor relationship. (You will be sent an Interim Status Report which will allow you to provide additional details about the program change.)

Site Closed

Question - Not Required - Site Name/Address:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Sponsoring Organization:

Question - Not Required - Please choose one of the following reasons:

This site remains in operation but no longer meets the standard.

The site closed.

Question - Not Required - Please provide the date and/or reason for your previous answer:

(Maximum response 255 chars, approx. 5 rows of text)

By submitting this online form, you are confirming you have reviewed the above information and attest to its accuracy.

*

Question - Required - Name of person submitting this change:

ERP change-of-info

Change in Quality Coordinator

Change in Coordinator Email Address

Change of Address or Phone Number

Name Change

Site Closed