| General Administration
- This section includes materials useful for the general administration and implementation of self management programs in clinic and community settings. Materials are organized by the nature of their use.
Assessment Materials, Forms & Instruments
Case Management Assessment Form (Open Door Health Center)
Case Management Check-in Form (Dept. of Family and Comm. Health/Marshall University)
Case Management Follow Up Form (Open Door Health Center)
Case Management Intake Form (Minneapolis American Indian Center)
Diabetes Clinical Form (Minneapolis American Indian Center)
Diabetes Group Visit Customer Feedback Form (St. Peter Family Medicine Residency)
Diabetes Group Visit Form (St. Peter Family Medicine Residency)
Diabetes Patient Survey (St. Peter Family Medicine Residency)
Diabetes Provider Visit Form (St. Peter Family Medicine Residency)
Diabetes Support Group/ Self Management Class Feedback Form (Center for African American Health)
Low Literacy Patient Assessment Tool 1 I 2 (Open Door Health Center)
Medical Assistant Confidence Level Survey (St. Peter Family Medicine Residency)
Medical Assistant Diabetes Survey (St. Peter Family Medicine Residency)
Participant Registration Form (Gateway Community Health Center)
Participant Registration Form Spanish (Gateway Community Health Center)
Patient Assessment Form (Dept. of Family and Comm. Health/Marshall University)
Patient Assessment Form (Gateway Community Health Center)
Patient Assessment Form Spanish (Gateway Community Health Center)
Patient Information Sheet English/Spanish (Open Door Health Center)
Patient Success Story Interview Form (Gateway Community Health Center)
Program Evaluation (Galveston County Health District)
Program Evaluation Telephone Survey (MaineGeneral Health)
Program Intake Form (Campesinos Sin Fronteras)
Program Intake Form (Galveston County Health District)
Project Enrollment Form (MaineGeneral Health)
Project Participant Assessment (Campesinos Sin Fronteras)
Project Participant Post-Test (Center for African American Health)
Project Participant Post-Test (Richland County Department of Health)
Project Participant Pre-Test (Center for African American Health)
Project Participant Questionnaire (Richland County Department of Health)
Resident Faculty Confidence Level Survey (St. Peter Family Medicine Residency)
Type II Diabetes Standing Orders (MA Planned Visit) (St. Peter Family Medicine Residency)
Program Management & Implementation
Barriers Identified for Diabetes Self Management (Open Door Health Center)
Barriers to Diabetes Self Management (Minneapolis American Indian Center)
Case Management Check-in Form (Dept. of Family and Comm. Health/Marshall University)
Case Management Intake Form (Minneapolis American Indian Center)
Certified Diabetes Educator Guidelines (Gateway Community Health Center)
Community Action Plan for Self Management (Minneapolis American Indian Center)
Community Health Worker Agreement (Open Door Health Center)
Community Health Worker Patient Phone Interview Script (Open Door Health Center)
Community Health Worker Roles and Responsibilities (Open Door Health Center)
Depression Referral Letter (La Clinica de La Raza)
Depression Screening and Follow Up Flow Chart (Gateway Community Health Center)
Diabetes Clinical Form (Minneapolis American Indian Center)
Diabetes Provider VIsit Form (St. Peter Family Medicine Residency)
Diabetes Visit Protocol (Minneapolis American Indian Center)
Goal Setting Contact Sheet (La Clinica de La Raza)
Group Medical Visit Consent Form (St. Peter Family Medicine Residency)
Guide to Stages of Change Interventions English (La Clinica de La Raza)
Guide to Stages of Change Interventions Spanish (La Clinica de La Raza)
Guide to Successful Holistic Program Implementation (Minneapolis American Indian Center)
Holistic Program Evaluation Tool (Minneapolis American Indian Center)
Informed Consent Form English (Gateway Community Health Center)
Informed Consent Form Spanish (Gateway Community Health Center)
Lay Health Educator Manual (MaineGeneral Health)
Move More Replication Kit (MaineGeneral Health)
Patient Flow Sheet (Community Health Center)
Patient Success Stories Form (Gateway Community Health Center)
Policies and Procedures for Referring Patients (Gateway Community Health Center)
Program Flow Sheet (Richland County Health Department)
Program Intake Form (Galveston County Health District)
Promotora Policies and Procedures (Gateway Community Health Center)
Recording Sheet (Gateway Community Health Center)
Referral Form (Gateway Community Health Center)
Self Management Call Back Cards (St. Peter Family Medicine Residency)
Self Management Goal Tracking Sheet (Community Health Center)
Topic Form (Community Health Center)
TTM Practical Guide for Providers (La Clinica de La Raza)
TTM Provider Cards (St. Peter Family Medicine Residency)
Type II Diabetes Standing Orders (MA Planned Visit) (St. Peter Family Medicine Residency)
Staff Training Materials & Methods
Certified Diabetes Educator Guidelines (Gateway Community Health Center)
Effective Strategies to Motivate and Encourage Healthy Lifestyle Changes (Montana-Wyoming Tribal Leaders Council)
Facilitating Group Visits (St. Peter Family Medicine Residency)
General Diabetes Information (Galveston County Health District)
Group Medical Visit Starter Kit (Dept. of Family and Comm. Health/Marshall University)
Guide to Successful Holistic Program Implementation (Minneapolis American Indian Center)
Lay Health Educator Manual (MaineGeneral Health)
Medical Assistant Confidence Level Survey (St. Peter Family Medicine Residency)
Medical Assistant Diabetes Survey (St. Peter Family Medicine Residency)
Medical Assistant Orientation and Skills Tool (St. Peter Family Medicine Residency)
Move More Replication Kit (MaineGeneral Health)
Promotora Policies and Procedures (Gateway Community Health Center)
Provider Diabetes and IGT (Impaired Glucose Tolerance): Patient Self Management Workshop (St. Peter Family Medicine Residency)
Resident Faculty Confidence Level Survey (St. Peter Family Medicine Residency)
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