Community e-Connect - eligibility survey

Complete 1 survey per state!

Question Title

* 1. Provide us with your state's programmatic contact information.

Name, Programmatic Contact

State Health Department

City/Town

State/Province

Email Address

Phone Number

Question Title

* 2. Provide us with your state's technical point of contact.

Name, Technical Contact

Email Address

Phone Number

Question Title

* 3. Provide the name of up to 2 clinical organizations you will be working with, as well as the EMR system they use and the approximate number of adult patients in their population. Indicate whether each EMR vendor has agreed or will agree to EMR modifications in writing.

Clinical organization 1

EMR system for clinical organization 1

Approximate number of adult patients in clinical organization 1

Has this EMR vendor agreed or will they agree to EMR modifications in writing? (Yes or No only)?

Clinical organization 2

EMR system for clinical organization 2

Approximate number of adult patients in clinical organization 2

Has this EMR vendor agreed or will they agree to EMR modifications in writing (Yes or No only)?

Question Title

* 4. Provide the names of up to 2 community-based organizations (CBO) you will be working with. Indicate what evidence-based interventions the CBO offers related to diabetes prevention/management and hypertension/high cholesterol management. Indicate whether each CBO has the capacity to handle an influx of referrals.

CBO 1

What evidence-based interventions does CBO 1 offer related to diabetes prevention/management and hypertension/high cholesterol management?

Does this CBO have the capacity to handle an influx of referrals? (Yes or No only)

CBO 2

What evidence-based interventions does CBO 2 offer related to diabetes prevention/management and hypertension/high cholesterol management?

Does this CBO have the capacity to handle an influx of referrals? (Yes or No only)

Question Title

* 5. Have your participating clinical and community-based organizations established or agreed to establish a legal agreement defining their relationship?

Yes, all organizations have agreed

Some, but not all, organizations have agreed

We don't yet have verbal agreements with these organizations

Question Title

* 6. Have your participating clinical and community-based organizations agreed to share individual-level data with one another?

Yes, all organizations have agreed

Some, but not all, organizations have agreed

We don't yet have verbal agreements with these organizations

Question Title

* 7. Have your participating clinical and community-based organizations agreed to share aggregate-level data with the SHD / NACDD / CDC?

Yes, all organizations have agreed

Some, but not all, organizations have agreed

We don't yet have verbal agreements with these organizations

Community e-Connect - eligibility survey

Complete 1 survey per state!

Question Title

* 1. Provide us with your state's programmatic contact information.

Question Title

* 2. Provide us with your state's technical point of contact.

Question Title

* 3. Provide the name of up to 2 clinical organizations you will be working with, as well as the EMR system they use and the approximate number of adult patients in their population. Indicate whether each EMR vendor has agreed or will agree to EMR modifications in writing.

Question Title

Question Title

* 5. Have your participating clinical and community-based organizations established or agreed to establish a legal agreement defining their relationship?

Question Title

* 6. Have your participating clinical and community-based organizations agreed to share individual-level data with one another?

Question Title

* 7. Have your participating clinical and community-based organizations agreed to share aggregate-level data with the SHD / NACDD / CDC?

Question Title

* 8. What other questions do you have for the NACDD technical assistance team? We will post questions and answers on the NACDD website.