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1 2 / 1 5 / 2 0 10 D e a r Jan e ,

Participant Interest and Retention Survey Fond du Lac Reservation. 1 2 / 1 5 / 2 0 10 D e a r Jan e ,

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1 2 / 1 5 / 2 0 10 D e a r Jan e ,

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  1. Participant Interest and Retention Survey Fond du Lac Reservation • 12/15/2010 • Dear Jane, • AsyourlifestylecoachfortheDiabetesPreventionProgram,Iwantedtocheckinandseewhatyourcurrentneedsand interestsare.Pleasetakeamomenttocompletethequestionsbelowandreturntomeinthepostage-paidenvelope. HappyHolidays- Jenn • Iwouldliketocontinueinthe DPP and participatein(pleasecircleallthatapply): • Requiredmedical appointmentsand lab • Group activities • Contactwithmylifestylecoach • Repeatgroupweeklyclasses (sit-inwith upcoming groups startingtheprogram) • OR • Iwould not liketocontinueinthe DPPbecause: • I feel comfortable with the information I learned in the program. I can continue my efforts to prevent diabetesonmyown andwill follow-upwithmymedical provider. • Other health problems • Familyproblems • Scheduling difficulties • I don’tliketheprogram • Other: • Ifyouare onlyinterestedinrequiredmedical appointmentsandlabs, orifyou arenolongerinterestedincontinuingthe program,youdonotneedtoanswerthe remainingquestions. • Howoftenwouldyou liketoparticipateinDPPgroupactivities? • Weekly • Twiceamonth • Monthly • Every3months • Pleaselistactivities you areinterested in: • Howwouldyouprefer tobecontacted by your lifestylecoach? • Schedulean individual appointmentfor discussionorphysical activity • E-mail (pleaselistyourcurrent e-mail) • Phonecall (pleaselistthephonenumber I shouldcontactyou duringclinic hours) • WhileattendingtheYOURWayAdultWeightManagementprogramatMNAW or CAIR. • I would prefer tocontact mylifestylecoach atleastevery3months. • Howoftenwouldyou liketoparticipateinlifestylecoaching? • Weekly • Twiceamonth • Monthly • Every3months

  2. Remember Your Purpose • Theseareyouranswers: • WhyIjoinedtheDiabetesPreventionProgram:“Mydoctor,becausemysugarwasa little high.” • What Ihopetoachievebytakingpart intheDPP:“Tonotget diabetes.” • Howhealthyeatingandbeingactive willhelp meand/or others:“Iwillfeelbetterand livealong healthylifeto enjoymyfamily.” • Jane’sProgram Goals • 7%weight lossgoal=165# • Dailyfat gram goal=42grams • Dailycaloriegoal=1,500calories • Activity goal=150minutesper week • Lifestyle Coaches • JenniferHall:878-2146;jenniferhall@fdlrez.com • KatieHughes:878-3794;kathleenhughes@fdlrez.com • ChrisFoss-Tietz:878-3709;chrisfosstietz@fdlrez.com • Amanda Thompson: 878-3731;amandathompson@fdlrez.com

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