*1.What is your name?(Required.)

*2.What is the name of the organization you represent?(Required.)

*3.What is your email address?(Required.)

*4.What geographic area(s) of North Carolina do you serve?(Required.)

*5.What areas of expertise can you contribute to the DAC? (ex: hearing/audiometry, endocrinology, DSMES, etc.).(Required.)

*6.Is your organization involved in diabetes prevention or management programs? Select all that apply(Required.)

Involved in National DPP

Involved in DSMES Program

Involved in diabetes prevention activities (other than DPP or DSMES)

Involved in diabetes management activities (other than DPP or DSMES)

None of the above 

N/A

*7.What is your current role at your organization? (Required.)

*8.Why are you interested in joining the DAC?(Required.)

*9.How do you see yourself contributing to the DAC?(Required.)

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