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2019 Know Your Numbers Diabetes Prevention Screening Campaign Site Participation Form

While the Diabetes Coalition engages in various assessments, prevention, and community educational outreach events throughout the year, the majority of these activities occur during our Know Your Numbers Diabetes Prevention Screening Campaign, which “kicks-off” at the beginning of National Diabetes Month each November and continues through January.

Yes, we would like to participate in the Know Your Numbers Diabetes Prevention Screening Campaign, by providing a Screening Site Venue for free Diabetes Risk Assessments and other Health Biomarker Screenings.

Please note: The Diabetes Risk Assessment is now being completed electronically via a tablet or computer. There are no paper forms. All Diabetes Risk Assessments are to be completed by the screener and not the participant.

Screening Site Participation Forms must be received by October 23, 2019 for events beginning in November. We will contact the person listed as the screening coordinator to discuss the screening event and to finalize arrangements for electronic completion of the risk assessments.
Diabetes Screening Site Contact Information
All fields on the form must be completed.
Organization Name:
Organization Address:
Organization Phone:
Contact For Organization:
Contact Cell Phone:
Contact Business Phone:
Contact Email:
Diabetes Risk Assessment Screening Date(s):
Date:
MM slash DD slash YYYY
Screening Times: From
To:
Date:
MM slash DD slash YYYY
Screening Times: From
To:
Date:
MM slash DD slash YYYY
Screening Times: From
To:
Date:
MM slash DD slash YYYY
Screening Times: From
To:
Date:
MM slash DD slash YYYY
Screening Times: From
To:
Diabetes Screening Site Address:
Contact for Screening Site and Volunteer Coordination
* if different from above
Name:
Contact Number:
Screening Services to be Offered
Is your site going to complete Diabetes Risk Assessments?
- Yes
- No
Do you need volunteers to help administer the diabetes risk assessment to participants?
- Yes
- No
How many volunteers?

If multiple days, please indicate # for each day
If multiple days, (please list dates, times, and number of volunteers needed):
Date:
MM slash DD slash YYYY
# of Volunteers Needed:
Times: From
To:
Date:
MM slash DD slash YYYY
# of Volunteers Needed:
Times: From
To:
Date:
MM slash DD slash YYYY
# of Volunteers Needed:
Times: From
To:
Date:
MM slash DD slash YYYY
# of Volunteers Needed:
Times: From
To:
Date:
MM slash DD slash YYYY
# of Volunteers Needed:
Times: From
To:
Do you need translator(s) to help administer the Diabetes Risk Assessment?
- Yes
- No
If yes, what languages
# of English:
# of Spanish:
# of Creole:
A1c Screenings
Due to limited funding, the Diabetes Coalition will only be able to provide free A1C testing kits and supplies to non-clinic sites. If providing A1c tests, these tests should be offered to all screening participants.
Is your site going to do A1c screenings?
- Yes
- No
Do you need A1c meters, test strips, and other testing supplies?
- Yes
- No
Do you need medical personnel to help with finger sticks?
- Yes
- No
Total anticipated Number of Participants:
(If you are doing multiple days, please provide Total Number of Participants for all of the days.)
Diabetes Screening Site Materials
Remember, if you are doing multiple site locations, please complete a separate form for each site.

Diabetes Risk Assessment Forms will now be completed via tablet or computer – There are no paper forms.
Please indicate if your clinic or organization has staff to administer the risk assessment to patients/clients without/independent of Coalition volunteers. We will contact the site coordinator to set up the web program and review the new risk assessment form.
- Yes
- No
How many Diabetes Risk Result Cards will you need
If you are doing multiple days, please provide total number for all of the days. Please note: The Diabetes Screening Result Cards will still be provided to sites. The completed cards are to be given to all screening participants.
# of English:
# of Spanish:
# of Creole:
Do you want goodie bags for your screening participants?
- Yes
- No
If yes, how many goodie bags:
Does your organization need a diabetes screening event sign?
- Yes
- No
If yes, how many signs:
Please list any other items that you will need. T-shirts will be provided for the volunteers. If staff need t-shirts, please provide number of t-shirts and sizes needed.
Please note: If you are providing educational items or promotional items, please have them delivered to Kaiser University by Monday, October 28, 2019. Please contact Debby Walters, Executive Director, to set up an appointment for delivery and for more details debby@diabetescoalitionpbc.org

CONTACT US

info@diabetescoalitionpbc.org

2051 MLK Jr. Blvd. Suite 306
Riviera Beach, FL 33404

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