American Diabetes Association: Survey - DPP Documentation Platform Interest Form

DPP Documentation Platform Interest Form

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1. How did you hear about us? (Maximum response 255 chars, approx. 5 rows of text)

2. Tell us about you

Field Is Required First

Field Is Required Last

State / Province:

Country:

Field Is Required E-mail:

Phone Number:

Yes, I would like to receive e-mail from American Diabetes Association

3. Field Is Required Organization Name: (Maximum response 255 chars, approx. 5 rows of text)

4. Field Is Required Are you currently employed with a Recognized Diabetes Self-Management Education Program?

5. Field Is Required What is your CDC DPRP Recognition Status?

6. Field Is Required How are you documenting your DPP Data?

7. If you select "Other", please describe (Maximum response 255 chars, approx. 5 rows of text)

8. If you select "Another Charting Platform", please name the platform (Maximum response 255 chars, approx. 5 rows of text)

9. Additional Comments

10. If you select one of the GDPR affected country in the above - As a resident of countries affected by GDPR, we are required to request your consent and acknowledgement that you authorize us to store your data by checking this box.