DEEP Application Workgroup Interview 2

Overview

Thank you for your interest in attending a three-day training to become certified as a Diabetes Empowerment Education Program™ (DEEP) peer educator. DEEP is a Medicare-approved, evidence-based diabetes self-management education (DSME) program developed by the Midwest Latino Health Research, Training, and Policy Center of the University of Illinois, Chicago. This training is offered at no cost by Health Services Advisory Group (HSAG) as part of the Centers for Medicare & Medicaid Services (CMS) Everyone with Diabetes Counts (EDC) initiative.

Please complete the following application interview to be considered to attend an upcoming three-day DEEP training.

Expectations Once Trained in DEEP

Identify locations to conduct a minimum of two DEEP workshops per year. DEEP workshops meet once a week for six weeks, and each weekly session lasts two hours (additional time should be taken into account for driving and preparation time).
Market DEEP workshops with a goal of registering:
- People with Medicare or of age 65 and older
- People who have pre-diabetes or diabetes
- At-risk subpopulations, including African-Americans, Hispanics/Latinos, American Indians/Native Americans, Asian/Pacific Islanders, rural area residents, and people in lower socio-economic ranks.
Ensure access to a vehicle or other form of reliable transportation to transport materials to the workshop locations you are facilitating.
Ensure participants complete and submit the required CMS forms, including an attendance log, registration forms, and pre- and post-activation surveys.

Question Title

* 1. I have read the expectations listed above, and agree that I am able to meet these expectations once I am trained in DEEP.

I agree

I do not agree

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* 2. Contact Information

First Name *

Last Name

Address *

City *

Organization Name *

ZIP/Postal Code *

Email Address *

Best Contact Number *

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* 3. List the languages you are fluent in.

English

Spanish

Other (please specify)

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* 4. What occupational degrees do you possess?

Beneficiary/Family/(Trained) Caregiver

Certified Diabetes Educator (CDE)

Community Health Worker (CHW)

Government Official

Trained Caregiver

Licensed Practical Nurse (LPN)

Registered Dietician (RD)

Social Worker (LCSW/MSW/DSW)

None

Other (please specify)

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* 5. Are you currently in a management role in your organization?

Yes

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* 6. Please provide the name of the HSAG staff member who referred you to the peer educator training.

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* 7. Indicate the location of the training you are interested in attending.

If the training you are interested in attending is not listed, it is at capacity. Please contact Joel Wingelman at 818.265.4660 to be put on a waiting list. Thank you.

This material was prepared by Health Services Advisory Group, the Medicare Quality Improvement Organization for California, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. CA-11SOW-B.2-01-031902019-01