Male Truck Driver Podcast Study Step 1 of 7 14% What is your Name?* First Last What is your email address?* What is your mobile number?*In which state do you live?*--Select--AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingHow did you hear about the program?*--Select--FacebookGoogleInstagramEmailWebsiteFleetUrgent CareSpouseFriendDon’t know/don’t rememberLead SourceICF ScreenerSubjectAre you a Veteran?NoLead CategoryScreeningDate Date Format: MM slash DD slash YYYY Consent?*By clicking NEXT, you have agreed to the following: You have read and understand the information in this document, You are willing to share your contact information with Omada, ADCES, and HTAA, You agree to be contacted by an HTAA Health Coach, and If you are eligible and you enroll in the Omada virtual diabetes prevention program, you agree to allow Omada to share identifiable information (see What information will be collected and shared? section above) with ICF.--Select--YesNoPlease enter why you have chosen not to consent. Are you an owner operator or do you work for a fleet?*--Select--Owner OperatorFleetWhat is your Trucking Company’s Name?* Which category best describes your age?*--Select--Under 3535-4546-5556-6566 or olderWhat was your assigned sex at birth?*--Select--MaleFemale We want to make sure we represent different ethnic and racial groups in our study. What is your ethnicity?Ethnicity*--Select--Hispanic or LatinoNot Hispanic or LatinoRace*--Select--American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhiteHispanic In the past 12 months, have you been told by a health professional that you have prediabetes or an A1c of 5.7% to 6.4%?*--Select--NoYes Which one of these categories describes the number of miles or hours you drive each day on average?*--Select--Fewer than 500 miles a day500 or more miles a dayFewer than 11 hours11 hoursHow would you describe the size of the trucking fleet you work for?--Select--Small: fewer than 250 trucks on the roadLarge: more than 250 trucks on the road
