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Lifestyle Coaches Application

Hi, this is Hanaa Sallam, MD, PhD, the director of the Diabetes Prevention Program (DPP) at UTMB. I invite you to fill in this survey to identify whether you are eligible for an intensive diabetes self-management education and support program at UTMB. If you do, we offer a free-of-charge educational program named iDSMES. This lifestyle change program features an approach to help you control your type 2 diabetes. By improving food choices and increasing physical activity, you can lose 5 to 7 percent of your body weight and have a better control of your type 2 diabetes.

The iDSMES program at UTMB is delivered by certified Lifestyle Coaches and Diabetes Care and Education Specialists. Enrolled participants will learn how to make and maintain lifestyle changes in group sessions of 10-15 participants per class. The groups meet every 3 weeks. Minimal attendance of sessions is required (9 sessions throughout the year-long program). Please refer to UTMB website to learn more (www.utmb.edu/diabetes).

Suppose you were found eligible to join the program; you will be prompted to select your preferred time for classes and enroll. It may take up to 2 months to start a class (we need to have 10-15 participants to start one class). Expect to hear from your lifestyle coach/educator 1 week before the class to send you educational material. If you have any questions/concerns, please do not hesitate to write in the comments, and we will get back to you timely. Thank you.

Hanaa Sallam, MD, PhD

hasallam@utmb.edu

1. Continue the survey if you are interested in knowing more, or

2. Close the webpage if you are not interested

To qualify for this program, you must be a Texas resident.
If you do not live in Texas, please simply close the window to exit the application. Thank you.

1. What is your name (first name and last name)?

* must provide value

2. How can we address you?

* must provide value

He, his, him She, her, hers They, them, theirs

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3. What is your highest degree?

* must provide value

High school Associate or some college College Postgraduate degree

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4. What is your email address?

* must provide value

5. What is your phone number?

* must provide value

6. Which statement best fits your situation?

* must provide value

I am affiliated with a CDC-recognized diabetes prevention program (DPP) that needs more lifestyle coaches in order to maintain, sustain, or expand the program.

I am affiliated with an ADCES/ADA/Stanford recognized/accredited Diabetes Self-Management and Education (DSME) program that wishes to expand services to include DPP.

I am not affiliated with any DPP or DSME programs.

Other (please specify)

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6a. Other status

7. Name your organization and location.

* must provide value

8. What is your position?

* must provide value

9. What is your Diabetes Prevention Recognition Program (DPRP) status?

* must provide value

Pending

Preliminary

Full

Full Plus

Not Applicable (no program yet)

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10. Why is it important for you/your organization to attend?

* must provide value

11. Has anyone from your organization been trained as a lifestyle coach? If so, how many?

* must provide value

Yes No

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11a. How many people from your organization have been trained?

12. How will your community benefit from this training?

* must provide value

13. What is the population you plan to serve?

* must provide value

14. Why do you want to be a lifestyle coach?

* must provide value

15. How do you image the role of a Lifestyle Coach?

* must provide value

16. Please name one skill that you think is essential to being a Lifestyle Coach.

* must provide value

17. Please describe any experience you have as a facilitator/trainer that could be relevant to a Lifestyle Coach.

* must provide value

18. Are you a UTMB staff or student?

* must provide value

Yes

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18a. What is your primary preferred dates for the training?

* must provide value

4 Days (Nov 18, 19 and Dec. 2, and 3)

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18b. What are your secondary preferred dates for the training?

* must provide value

4 Days (Nov 18, 19 and Dec. 2, and 3)

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19a. What are your primary preferred dates for the training?

* must provide value

Nov., 6-9

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19b. What are your secondary preferred dates for the training?

* must provide value

Nov., 6-9

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Thank you for applying for the lifestyle coach training at UTMB. Our Master Trainer SelectTM may contact you for an interview 1-2 weeks before the training date. You are now enrolled in your first choice of class unless otherwise communicated. Expect to receive the training material and agenda one week prior to your training. If you have any questions, please contact Hanaa Sallam, MD, PhD, CDCES hssallam@utmb.edu". Finally, please click "Submit" to exit this form. Thank you.

You have selected an option that triggers this survey to end right now.

To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.