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About You
First Name
Last Name
Email
Employer
Job Title
Street Address
Please make sure to include ALL INFORMATION NEEDED for accurate delivery of your materials. This includes building names and numbers, suite or apartment numbers, company or organization names, etc. If your address is not entered in correctly, your materials will be returned. We then spend valuable time and resources confirming your address, and paying for new shipment of materials. Please help us help you and spend the extra few seconds to confirm your address is correct!
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City
Postal Code
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
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Phone
Birthdate (mm/dd/yyyy)
Race/Ethnicity
Please select...
White
Black or African American
Hispanic or Latino
Native American or American Indian
Asian/Pacific Islander
Other
I prefer not to say
Ethnicity Other
Please Describe yourself!
Campus Professional
Diabetes Camp Professional
Diabetes Organization Professional
Clinical Provider
High School Student
College Student
Alumni
Media
Parent of a student with T1D
Other
Please describe yourself
Clinical Provider
Please select...
Endocrinologist - Adult Provider
Endocrinologist - Pediatric Provider
Certified Diabetes Educator (CDE)
RN/NP/Nurse - Diabetes Focus
Psychologist/Social Worker - Diabetes Focus
Diabetes Clinical Provider - Other
Not specialized in diabetes
Not specified
High School
High School Graduation
Campus Professional
Please select...
Professor/Faculty
Dining Services
Residential Life
Student Affairs
Admissions
Health Services
Disabilities/Auxiliary Services
Other
Not specified
Undergraduate School
Undergraduate Major
Date of Undergraduate Graduation
Materials
Type of Materials - Please select all that apply
Please select...
Off to College Booklets
Off to College Event Hosting Kit (for event hosts)
CDN Brochures
Off to College Hosting kit includes 50 Brochures and Off to College Booklets
What is the purpose of these materials
Personal Use
Campus Health Center
Disabilites/Auxiliary Services
Clinic Use
Community Organization Event
Diabetes Camp
Hosting an Off to College Event
Chapter Programming
Other
Purpose of Materials - Other
Number of brochures requesting
Please select...
25
50
75
100
125
150
175
200
Have you held an "Off to College" or transition event in the past?
Yes
No
What was the approximate date of your first event like this?
When do you plan to host the upcoming event (approximate is fine!)
How many attendees do you anticipate will attend (approximate is fine!)
Please select...
1-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-100
101-200
More than 200
Do you currently have involvement with CDN students for this event?
Please select...
Yes, and I would like to include them as panel speakers at my event
No, but I would like to include CDN students as panel speakers at my event
Yes, but I'm not interested in involving them in my event
No, and I'm not interested in involving them in my event
Any reason why not?
other
How many Off to College Student Booklets will you need? Please note, they are sent in packages of 10.
Please select...
10
20
30
40
50
60
70
80
90
100
How many Off to College Caregiver Booklets will you need? Please note, they are sent in packages of 10.
Please select...
10
20
30
40
50
60
70
80
90
100
How many Off to College Student Booklets do you need? Please note, they are sent in packages of 10.
Please select...
10
20
30
40
50
60
70
80
90
100
How many Off to College Caregiver Booklets do you need? Please note, they are sent in packages of 10.
Please select...
10
20
30
40
50
60
70
80
90
100
How many Off to College Student Booklets will you need? Please note, they are sent in packages of 10.
Please select...
10
20
30
40
50
60
70
80
90
100
How many Off to College Caregiver Booklets will you need? Please note, they are sent in packages of 10.
Please select...
10
20
30
40
50
60
70
80
90
100
How many Off to College Student Booklets will you need? Please note, they are sent in packages of 10.
Please select...
10
20
30
40
50
60
70
80
90
100
How many Off to College Caregiver Booklets will you need? Please note, they are sent in packages of 10.
Please select...
10
20
30
50
40
60
70
80
90
100
How many Off to College Student Booklets will you need? Please note, they are sent in packages of 10.
Please select...
10
20
30
40
50
60
70
80
90
100
How many Off to College Caregiver Booklets will you need? Please note, they are sent in packages of 10.
Please select...
10
20
30
40
50
60
70
80
90
100
How many Off to College Student Booklets will you need? Please note, they are sent in packages of 10.
Please select...
10
20
30
40
50
60
70
80
90
100
How many Off to College Caregiver Booklets will you need? Please note, they are sent in packages of 10.
Please select...
10
20
30
40
50
60
70
80
90
100
Which booklet(s) would you like a copy of?
Please select...
Student
Caregiver
Student and Caregiver
How many Off to College Student Booklets will you need? Please note, they are sent in packages of 10.
Please select...
10
20
30
40
50
60
70
80
90
100
How many Off to College Caregiver Booklets will you need? Please note, they are sent in packages of 10.
Please select...
10
20
30
40
50
60
70
80
90
100
Off to College Student Questions
Have you started college yet?
Yes
No
When do you plan on starting college? Approximate date is fine!
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Year
Please select...
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
On a scale of 1 through 6, with 1 being "not at all prepared" and 6 being "extremely prepared", how well prepared do you feel about managing your diabetes at college?
1
2
3
4
5
6
I plan to (or already have) register for accommodations in college for diabetes.
Yes
No
I haven't decided yet
What accommodations did you request?
What accommodations did you receive?
Are you satisfied with your experience registering for accommodations?
Totally unsatisfied
Unsatisfied
Satisfied
Totally satisfied
On a scale of 1 through 6, with 1 being "incredibly uncomfortable" and 6 being "incredibly comfortable", how comfortable do you feel
talking to peers
about your diabetes?
1
2
3
4
5
6
On a scale of 1 through 6, with 1 being "incredibly uncomfortable" and 6 being "incredibly comfortable", how comfortable do you feel
talking to professors
about your diabetes?
1
2
3
4
5
6
Please select the TOP THREE topics that you are most interested in learning more about (only three, please!)
Finding a college
Preparing for the move to college: Supplies and packing
Sick days
Accommodations
Drinking
Navigating the parent/child relationship in college
Nighttime lows on campus
Using diabetes technology on campus
Other (please describe)
Please describe any other top three topics you are interested in learning more about.
What are you most excited for about college?
What are you most nervous about attending college?
Off to College Parent Questions
Is your child currently attending college?
Yes
No
When does your child plan to start college? Approximate date is fine!
Please select...
January
February
March
April
May
June
July
August
September
October
November
December
Year
Please select...
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
What college/university is your child planning on, or interested in, attending?
Does your child plan to live at home or on campus?
At home
On campus
They haven't decided yet
Other (please explain)
Other
Is your child anticipating changing, or have they already changed, healthcare providers closer to their college?
Yes
No
Undecided
Keeping two providers, 1 near home and 1 near school
I feel anxious about my child going to college with diabetes.
Strongly disagree
Disagree
Agree
Strongly agree
I have sufficient resources to help my child transition to college with diabetes.
Strongly disagree
Disagree
Agree
Strongly agree
Please select the TOP THREE topics that you are most interested in learning more about (only three, please!)
Finding a college
Preparing for the move to college: Supplies and packing
Sick days
Accommodations
Drinking
Navigating the parent/child relationship in college
Nighttime lows on campus
Using diabetes technology on campus
Other (please describe)
Please describe any other top three topics you are interested in learning more about.
What are you most excited for about your child attending college?
What are you most nervous about for your child attending college?
Anything else you would like to ask?
How did you hear about CDN?
Please select...
Google Search
Off to College Event
CDN Website
CDN Newsletter
Diabetes Camp
Social Media
Word of mouth
Printed Materials
CDN Chapter/CDN Student Member
Parent/Caregiver
Child
Endo/CDE/Clinician
Other
Would you like to be updated on CDN news and announcements?
Yes
No
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