The American Diabetes Association needs your feedback to ensure we are providing the right information in the right way.
You can take the survey now, if you're ready, or take it later after you've spent more time on the site.
Thank you in advance for your help!
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Become a Member
Learn more about the Health Care Professionals Legal Advocacy Network at http://www.diabetes.org/patientrights
(for reaching you as a network member)
Your Professional Website (or LinkedIn):
Place of Business:
Home Phone (optional):
1. Which of the following credentials do you currently hold? Select all that apply.
Doctor of Medicine (MD) Doctor of Osteopathy (DO) Doctorate (PhD) Registered Nurse (RN) Nurse Practitioner (NP) Physician’s Assistant (PA) Registered Dietitian (RD) Social Worker (MSW) Diabetes Educator Registered Pharmacist (RPh)/Doctor of Pharmacy (PharmD) Other (specify):
2. Please state your specialty
3. In which setting(s) do you work? Select all that apply.
Hospital Clinic Academic/Research School Self-Employed Other (specify):
4. Please indicate your expertise and knowledge about diabetes.
5. Are you a Certified Diabetes Educator (CDE)?
6. If you provide health care services in languages other than English, please list them
7. Please select all states in which you are willing to volunteer as an HCP Network Member.
8. In which of the following areas are you interested in providing service, as an HCP Network Member? Select all that apply.
EmploymentEducationDaycare/ChildcareCorrectional FacilitiesPolice MisconductPublic AccommodationsDriver's LicensesOther
9. In which of the following functions are you interested in providing service, as a Network Member? Select all that apply.
Assisting with the development of diabetes-related educational materialsEducating individuals about their rights (e.g. presentations, lectures)Making phone calls (e.g. calling employers, schools, etc.)Writing letters (e.g. requesting school/work accommodations, etc.)Training school personnel in diabetes care management in school settingsTraining police departments on appropriately responding to individuals with diabetesTraining jails and prisons on diabetes care management in correctional settingsTraining other health care professionals on diabetes discrimination issuesConsulting with attorneys on legal cases (i.e. giving advice, analyzing health-related claims, explaining medical conditions)Being an expert witness at trialsSupporting the Association’s legislative effortsHelping to recruit new members of the HCP Legal Advocacy Network
10. How did you learn about the Health Care Professional (HCP) Legal Advocacy Network?
Professional ColleaguePresentation at conference/meeting/other eventAmerican Diabetes Association websiteAmerican Diabetes Association magazineAmerican Diabetes Association email
ADA Health Care Professional Legal Advocacy Network Business Card
Other (specify below)
11. What was the primary motivation for you to become a member of the HCP Legal Advocacy Network?
I have a strong personal connection to diabetes (e.g., self, child, other family member, friend with diabetes)I wanted to volunteer/advocate for an important cause I wanted to leverage my professional skills/experience in a meaningful way Other (specify below):
12. How have you have been involved with the American Diabetes Association? Select all that apply.
Joined the Stop Diabetes movementSubscribed to Diabetes Forecast magazineSubscribed to a professional member publicationSubscribed to e-newslettersDonated moneyVolunteered (in a Non-Advocacy Attorney Network capacity)Attended a Diabetes EXPOPurchased books, materials, or videos from the American Diabetes Association’s online storeParticipated in Step Out: Walk to Stop Diabetes eventParticipated in a Tour de Cure eventChild attended a Diabetes CampParticipated in an online message boardParticipated (or child participated) in School Walk for Diabetes eventAttended the Scientific Sessions ConferenceOther (specify below):
13. The HCP Legal Advocacy Network Listserv, carefully moderated by experts, provides a valuable forum for discussion about discrimination due to diabetes. If you prefer that we use an email other than the address you provided above, list it here
14. Check the box below —
15. If you want to recommend a colleague for us to contact for recruitment into the HCP Network or the Advocacy Attorney Network, please list their name(s), email address(es), and professional title(s).
By completing this form, you are signing up to participate in the ADA Health Care Professionals Legal Advocacy Network
I am ready to help
I have questions and would like to speak to a staff member before I help
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