Diabetes Month 2017 Screening Site Participation Form

Yes, we would like to participate in Diabetes Week 2017 by providing a Screening Site Venue for free Diabetes Risk Assessments and Glucose Screenings.

If you are doing multiple (separate) site locations, please complete a separate form for each site.

Site Participation Forms Must be Received by Wednesday, October 18th, 2017

All fields on the form must be completed.

Please note: A1c tests should only be offered to those individuals who have a 4 or higher score on the Diabetes Risk Assessment, or 5 or higher ages 60 or over.

Remember, if you are doing multiple site locations, please complete a separate form for each site.

If you are doing multiple days, please provide total number for all of the days. Please note: the same number of “Know Your Number Cards” will be included.