Diabetes Prevention Program Eligibility Form

Please complete this confidential form (seen by only the UC Berkeley Diabetes Prevention Program Coordinator and trained Lifestyle Coaches) and the Prediabetes Risk Test at https://www.cdc.gov/prediabetes/takethetest/ if you believe you are a good candidate for the Diabetes Prevention Program or if your physician has recommended that you start a lifestyle change program.

The Diabetes Prevention Program (DPP) is a one-year lifestyle change program designed for adults who have prediabetes or are at risk for developing type 2 diabetes. Through a collaboration with the University of California Office of the President/UC Health, and the Healthy Campus Initiative, DPP is offered for UC Berkeley staff, faculty, students, and spouses.

During the year-long program, a small group of participants and their lifestyle coach meet in a virtual distance learning setting once a week for the first three months, biweekly for month four (every other week), and once a month for the remainder of the program. The group sessions create a space for participants to discuss barriers and to find solutions together. DPP uses a CDC approved curriculum which includes basic information on nutrition, ways to increase physical activity, stress management techniques, and ideas to stay motivated.

For more information, please visit: https://uhs.berkeley.edu/dpp

Who is completing this form? *
DPP Candidate/Participant
Physician/Provider
Other
Participant Name *
First Last
UC Berkeley ID Number *
Email *
Phone number *
### - ### - ####
Affiliation with UC Berkeley *
Faculty
Staff
Undergraduate Student
Graduate Student
Spouse
Campus Department
Are you Union represented? *
Yes
No
Sex *
Female
Male
Decline to state
Other
Gender (How do you describe yourself)? *
Female
Male
Transgender
Other
Age *
Home Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Race (select all that apply) *
White
Asian
Native Hawaiian or other Pacific Islander
Black or African American
American Indian or Alaska Native
Prefer not to answer
Ethnicity *
Hispanic or Latinx
Non Hispanic or Latinx
Education *
Less than grade 12 (No high school diploma or GED)
Grade 12 or GED (High school graduate)
College - 1-3 years (Some college or technical school)
College - 4 years or more (College graduate)
Advanced Degree (e.g. PhD, MD, MS, MA, MPH, MBA)
Who/what motivated you the most to sign up for the program? *
Health Care Professional
Blood test result
Prediabetes risk test (short survey)
Someone at a community based organization (church, community center, fitness center)
Family or friends
Current or past participant in the National DPP LCP
Employer or employer’s wellness plan
Health Insurance Plan (UC Mailer)
Media advertisements (social media, flyer, brochure, radio ad, billboard, etc.)
Other
Did you receive a UC Health DPP invitation letter in the mail? *
Yes
No
Did a healthcare professional ask you to join the program? *
Yes, a doctor/doctor’s office
Yes, a pharmacist
Yes, other healthcare professional
No
In the last 3 months have you completed an A1c test? *
Yes
No
Please indicate the results. (Ex: 2.5 to 18) *
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