Health Screener National Diabetes Prevention Program We are pleased you have decided to participate in the National Diabetes Prevention Program. 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 rememberHiddenLead SourceWebHiddenSubject HiddenAre you a Veteran?NoHiddenLead CategoryDPP LCPHiddenDate MM slash DD slash YYYY Consent?*We need your consent: You are willing to share your contact information with with HTA. You agree to be contacted by an HTA Health Coach, and If you are eligible and you enroll in a virtual DPP diabetes prevention program, you agree to allow HTA to share identifiable information with a DPP Provider. See full disclosure--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?* What is your Date of Birth?* MM slash DD slash YYYY What 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
