Who is answering this survey?
Child or teenager 18 and under with diabetes
Parent of child or teenager 18 and under with diabetes
This survey is for kids and teens 18 years and under or their parents.
Where do you live?
USA
Canada
Mexico
Europe
Asia
Australia/NZ
Other (please specify)
How many people are living in your home?
One
Two
Three or more
Age of child or teenager with diabetes?
Is the child or teenager with diabetes a boy or girl?
Boy
Girl
What is the ethnic background of child or teenager with diabetes?
Caucasian
African American
Oriental
Native American
Other
What was the age when diabetes was first diagnosed?
What kind of doctor or specialist is seen for diabetes? (Check all that apply.)
Pediatrician
Family or general practitioner
Specialist (endocrinologist or diabetologist)
Diabetes Educator
Other healthcare professional
Don't know
How is diabetes being controlled? (Check all that apply.)
Insulin
Pills
Diet
Exercise
Are blood glucose levels tested at home or away from home (not at doctor's office) with a meter?
Yes
No
If you don't use a meter at home or away from home, please skip to the Information and Internet Use questions.
About how often is blood glucose tested with a meter either at home, away from home or school?
5 or more times a day
4 times a day
3 times a day
2 times a day
Once a day
Less than once a day
How many meters do you use?
What brands of meters do you use? (Check all that apply.)
Glucometer Encore
Glucometer Elite
Other Glucometer or Bayer / Ames / Miles
Accuchek I / II / III
Accuchek Instant
Accuchek Easy
Accuchek Advantage
Other Boehringer Mannheim
One Touch Basic
One Touch (Original)
One Touch Profile
One Touch II
SureStep
Other LifeScan / One Touch
ExacTech Companion
ExacTech Companion 1 or 2
ExacTech Companion Jr.
ExacTech RSG
Precision QID
Other MediSense / ExacTech
Other Meter Brand
If more than one meter is used, what brand is used most often? (Select one.)
Glucometer Encore
Glucometer Elite
Other Glucometer or Bayer / Ames / Miles
Accuchek I / II / III
Accuchek Instant
Accuchek Easy
Accuchek Advantage
Other Boehringer Mannheim
One Touch Basic
One Touch (Original)
One Touch Profile
One Touch II
SureStep
Other LifeScan / One Touch
ExacTech Companion
ExacTech Companion 1 or 2
ExacTech Companion Jr.
ExacTech RSG
Precision QID
Other MediSense / ExacTech
Other Meter Brand
At what locations are meters used? (Check all that apply.)
At home
At school
At daycare or after school care
Other places away from home
How satisfied are you with meter you use most often?
Completely satisfied
Very satisfied
Somewhat satisfied
Not very satisfied
Not at all satisfied
How likely are you to recommend the meter you use most often to another child or teenager who has diabetes?
Definitely recommend
Probably recommend
Might or might not recommend
Probably not recommend
Definitely not recommend
Information and Internet Use Questions
Where do you look for information about diabetes? (Check all that apply.)
From parents
From doctor/specialist
From support groups
Diabetes Magazines
The Internet
When did you first visit the children with DIABETES website?
Within the past month
Within the past 6 months
Within the past year
Over a year ago
I don't remember
How often do you visit the children with DIABETES website?
Every day
More than once a week
Once a week
Less than once a week
This is my first visit
How useful is the children with DIABETES website?
Extremely useful
Very useful
Somewhat useful
Not very useful
Not at all useful
What types of information on the children with DIABETES website are most useful to you? (Check all that apply.)
Chat rooms
News about research
Other news
Ask the Diabetes Team Questions and Answers
General information about diabetes
Product reviews
Message board
Food and diet
Kids, parents and adults stories
Camps
School information
Diabetes dictionary
Check which of the following kinds of information you would like to have available on the children with DIABETES website. (Check all that apply.)
General research on diabetes
Information on new products
Research studies looking for participants
Research on cure for diabetes
Children's rights at school
Other (fill in)
What, if any, of the following diabetes websites have you visited? (Check all that apply.)
Juvenile Diabetes Foundation
American Diabetes Association
American College of Physicians
Diabetes Monitor
Local ADA Affiliates (independent websites)
Diabetes and Hypoglycemia Forum on CompuServe
Medilife
Diabetes UK
On-Line Resources for Diabetics
Where do you access the Internet? (Check all that apply.)
Home
At school
At friends
At office
For what reasons do you usually go on the Internet? (Check all that apply.)
Sports/news/weather
Education/information
Shopping
E-mail
Chatroom
Games
Other reasons (please fill in)
How many hours a week do you usually spend on the Internet?
Less than one hour a week
One to two hours a week
Three to five hours a week
Six to ten hours a week
Over ten hours a week
Please answer questions 28 to 32 only if you are the parent of a child with diabetes who uses a meter:
How likely would you be to buy products over the Internet using a credit card, that is providing your credit card information on-line in order to make the purchase?
Have already bought
Definitely would buy
Probably would buy
Might or might not buy
Probably not buy
Definitely not buy
How likely would you be to buy products over the Internet by calling an off-line customer service number and giving your credit card information over the phone?
Have already bought
Definitely would buy
Probably would buy
Might or might not buy
Probably not buy
Definitely not buy
Which of the following types of products, if any, would you consider buying on a diabetes website? (Check all that apply.)
Diabetes medications
Diabetes home testing products (meters, strips, lancing devices, etc.)
Clothing (T-shirts, shoes, etc.)
Diabetes informational materials (videos, books, etc.)
Personal care items (soap, toothpaste, etc.)
General non-prescription drugs (cold/flu, pain relievers, etc.)
None of these products
Which of the following statements best describes how the last blood glucose meter was bought?
Paid for the product with your own money and then sent in an insurance form to receive money back
Paid for the product with your own money but your insurance company at the time did not cover that item
You paid for the product with your own money because you had no health insurance at the time
You presented a card to your pharmacist and paid a small amount of money for the product, sometimes called a co-pay
You received the product free and there for didn't have to pay for it with your own money
Don't know how the most recent meter was bought
Which of the following statements best describes how the last box of strips was bought?
Paid for the product with your own money and then sent in an insurance form to receive money back
Paid for the product with your own money but your insurance company at the time did not cover that item
You paid for the product with your own money because you had no health insurance at the time
You presented a card to your pharmacist and paid a small amount of money for the product, sometimes called a co-pay
You received the product free and there for didn't have to pay for it with your own money
Don't know how the most recent box of strips was bought
The remaining questions are for everyone.
Would you be interested in participating in an on-line discussion group on your experiences with diabetes and products for treating diabetes?
Yes
No
If you are interested, please enter your e-mail address so we can contact you. Your e-mail address will not be used for any other purpose.
If you would like to add any comments, please do so here.