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Ada Survey

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Submitted By mikelee17
Words 454
Pages 2
Survey Questions 1. What is your gender? a. Male b. Female

2. Please select your age category: c. 0-18 d. 19-39 e. 40-49 f. 50-59 g. 60+

3. What is your race/ethnicity? h. White i. Hispanic or Latino j. Black or African American k. Native American or American Indian l. Asian / Pacific Islander m. Other

4. What is your knowledge about Diabetes? n. I am very knowledgeable o. I am somewhat knowledgeable p. I have heard of the disease q. I know nothing 5. What is your knowledge about The American Diabetes Association (ADA)? Please select all that apply r. I do not know anything s. I have heard of the ADA t. I have been to their website u. I have attended an event v. I have volunteered for the ADA w. Other_____________________

6. How are you personally affected by Diabetes? (Choose the one that most accurately describes you) x. I have Diabetes y. A direct family member has been diagnosed z. I know someone that has Diabetes {. I am a care-giver of someone that has Diabetes |. I have been informed by a medical professional that I am at risk for Diabetes }. I am personally not affected by Diabetes

7. If you have been diagnosed with Diabetes, what type do you have? ~. Type I . Type II . Gestational Diabetes . N/A 8. How would you categorize your involvement within the community? . Very involved . Somewhat involved . Rarely involved . Never involved

9. Have you ever participated in a fundraising/awareness event for a medical cause? . Yes . No

10. If yes, what was your main reason for participating in those events? (Choose which reason most accurately describes you) . I have/had the medical condition . I have a direct family member who is/was affected by the medical condition . I know a friend who has been affected by the medical condition . I participated with a group of friends . Participated on behalf of another organization I was involved in . Motivation is not directly associated with medical condition

11. What type of event would you be most inclined to participate in? . Physical Event (ex. Sporting event) . Non-Physical Event (ex. Banquet) . I would not attend one of these events

12. Which type of physical event would you be most likely to attend? . Walk/Run . Bike . Triathlon . Dance Marathon . Not interested in a physical event . Other participative sports (ex Basketball, soccer, jump rope, etc.) ________________________________

13. Which type of non-physical event would you attend? . Banquet . Silent Auction . Retail Event (ex. x amount of the proceeds go towards the cause) . Not interested in a non physical event . Other

14. If you would be willing to be contacted for additional questioning, please provide this information. Phone: _____________________________ Email: ______________________________

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