Screen Reader Mode Icon Check SCREEN READER MODE to make this survey compatible with screen readers. Sign up for Chronic Disease, Chronic Pain, and/or Diabetes Self-Management workshops or Fit and Strong or Health Coaches for Hypertension Control Workshops Question Title * 1. Name: OK Question Title * 2. Phone number: OK Question Title * 3. Email Address: OK Question Title * 4. What city or town do you live in? OK Question Title * 5. Sign up for a Self-Management workshop (all workshops are 6 weeks, with one session per week): Chronic Disease (for people with chronic disease or a caregiver), Chronic Pain (for people with chronic pain or a caregiver), and/or Diabetes Self-Management (diabetics, pre-diabetes and caregivers,). Yes No Would like more information Chronic Disease Self-Management Workshop Chronic Disease Self-Management Workshop Yes Chronic Disease Self-Management Workshop No Chronic Disease Self-Management Workshop Would like more information Chronic Pain Self-Management Workshop Chronic Pain Self-Management Workshop Yes Chronic Pain Self-Management Workshop No Chronic Pain Self-Management Workshop Would like more information Diabetes Self-Management Workshop Diabetes Self-Management Workshop Yes Diabetes Self-Management Workshop No Diabetes Self-Management Workshop Would like more information OK Question Title * 6. For Chronic Disease, Chronic Pain. and Diabetes Self Management classes have two ways we can teach the class. One-hour class is a shorter, more condensed version of the 2.5 hour class. Both versions of the class are for 6 sessions for 6 weeks. Would you like to attend: One-Hour class 2.5 hour Class Either class OK Question Title * 7. What time(s) works best for Chronic Disease, Chronic Pain. and Diabetes Self-Management Workshop. Morning (between 9 am and Noon) Afternoon (Between 1:30 pm and 5 pm) Evening (starting at or after 5 pm Other (please specify) OK Question Title * 8. Fit & Strong! (24 sessions each 90 minutes over 8 or 12 weeks). What workshop would you like to sign up for: Over 8 weeks, on Monday, Wednesday, and Fridays for 90 minutes each session Over 12 weeks, on Monday and Wednesday for 90 minutes each session Over 12 weeks, on Tuesday and Thursday for 90 minutes each session OK Question Title * 9. Health Coaches for Hypertension Control (help people with high blood pressure better manage their condition) for 1.5 hours weekly for 8 weeks. Morning (between 9 am and Noon) Afternoon (Between 1:30 pm and 5 pm) Evening (starting at or after 5 pm Other (please specify) OK DONE