screener – Shift Into Better Health

National Diabetes Prevention Program

We are pleased you have decided to participate in the National Diabetes Prevention Program.

Step 1 of 7

What is your Name?*
First Last
What is your email address?*
What is your mobile number?*
In which state do you live?*
How did you hear about the program?*
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Lead Source
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Subject
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Are you a Veteran?
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Lead Category
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Date
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
Please enter why you have chosen not to consent.

Are you an owner operator or do you work for a fleet?*
What is your Trucking Company’s Name?*

What is your Date of Birth?*
MM slash DD slash YYYY
What was your assigned sex at birth?*

We want to make sure we represent different ethnic and racial groups in our study. What is your ethnicity?
Ethnicity*
Race*

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%?*

Which one of these categories describes the number of miles or hours you drive each day on average?*
How would you describe the size of the trucking fleet you work for?