American Diabetes Association: Survey - Why Do YOU Want to Stop Diabetes®?

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Why Do YOU Want to Stop Diabetes®?

Your answers to the few short questions below will help us better serve you in our mission to cure, prevent and better treat diabetes. Thank you!

1.

Email Address:


*	E-mail: Required
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2.

Question - Not Required - Why do you want to Stop Diabetes®? Select all that apply.

	I have type 1 diabetes
	I have type 2 diabetes
	I have/had gestational diabetes
	I have pre-diabetes
	My child has diabetes
	A friend/loved one has diabetes
	I'm at risk for diabetes
	I am a health care professional with an interest in stopping diabetes
	I just want to Stop Diabetes®

3.

Question - Not Required - What diabetes issues are YOU most interested in? Select all that apply.

	Supporting research to prevent, manage and cure diabetes
	Improving access to quality, affordable health coverage for people with diabetes
	Ending discrimination against people with diabetes
	Fighting to give children with diabetes access to the care they need to stay healthy, learn, and be safe at school
	Supporting diabetes prevention through access to healthy foods and physical education in schools

4.

Question - Not Required - How have you engaged with the American Diabetes Association other than donating? Select all that apply.

	Received Diabetes Forecast magazine
	Received an American Diabetes Association professional member publication
	Received American Diabetes Association e-newsletters
	Participated as a volunteer for the American Diabetes Association
	Attended a Diabetes EXPO
	Contacted your elected officials about important diabetes legislation
	Purchased books, materials, or videos from the American Diabetes Association
	Made a Gift of Hope purchase
	Participated in a Tour de Cure cycling event
	Participated in a Step Out Walk to Stop Diabetes event
	Child attended an American Diabetes Association diabetes camp
	Participated in an American Diabetes Association online message board
	Participated (or child participated) in school Walk for Diabetes event
	I am not involved with the American Diabetes Association in any other way

5.

Question - Not Required - In what age range do you fit? <18
18-25
26-35
36-45
46-55
56-65
66-75
76+
Prefer not to answer

6.

Question - Not Required - What is your gender? Male
Female

7.

Question - Not Required - What is your race/ethnicity? Native American
African American
Latin American/Hispanic
Asian/Pacific Islander
Caucasian/White
Other

8.

Question - Not Required - What is your annual household income? Less than $15,000
$15,001 to $25,000
$25,001 to $35,000
$35,001 to $50,000
$50,001 to $75,000
$75,001 to $100,000
$100,001 to $150,000
More than $150,000
Prefer not to answer

9.

Question - Not Required - Has the American Diabetes Association positively affected your life? Let us know! Your words could be featured on the web, used in promotional materials, or published in a future issue of the e-newsletter. This is an anonymous survey so please include your name if we may use it.

Spam Control Text: Please leave this field empty

American Diabetes Association
2451 Crystal Drive, Suite 900
Arlington, VA 22202 1-800-DIABETES (800-342-2383)

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