Please feel free to use any of our MDRC Survey Instruments. We just ask that you please cite our center as follows: The project described was supported by Grant Number P30DK020572 (MDRC) from the National Institute of Diabetes and Digestive and Kidney Diseases.
For additional questions, please reach out to Shay Aboutawila at shollamo@umich.edu
The Michigan Diabetes Research Center (MDRC) has developed several survey instruments for diabetes patients and health professionals. By downloading the forms you are agreeing to acknowledge the MDRC as the source of the items in the survey instruments in any written instruments, reports, or publications resulting from their use or reproduction.
Please select the instruments you would like to download from the list below . These instruments are all available in both Word format and PDF format. (Adobe Acrobat Reader is required to view and print PDF files. If you don't already have Adobe Acrobat Reader, you can download it for free now.)
Translations
The Michigan Survey Instruments have already been translated into multiple international languages. Please find further information on the existing translations on Mapi Research Trust website at: https://eprovide.mapi-trust.org.
Diabetes Care Profile (DCP)
The DCP is a self-administered questionnaire that assesses the social and psychological factors related to diabetes and its treatment. The instrument contains 234 items and sixteen scales. These scales assess the patients' diabetes attitudes, diabetes beliefs, self-reported diabetes self-care, and difficulties with diabetes self-care. The DCP also contains questions concerning demographic information and self-care practices. Respondents can complete the questionnaire in approximately 30 to 40 minutes.
Diabetes Care Profile Scale Formulae (Word)
Diabetes Care Profile Scale Formulae (PDF)
List of articles concerning or using the DCP (Word)
List of articles concerning or using the DCP (PDF)
Diabetes Knowledge Test - (DKT)
The Diabetes Knowledge Test consists of 23 knowledge test items developed by the Michigan Diabetes Research Training Center (MDRC). These 23 items represent a test of general knowledge of diabetes. The first 14 items are appropriate for people who do not use insulin. The entire 23 items can be administered to people who do use insulin. The psychometric properties provide information regarding the reliability of the various groups of items, as well as a difficulty index (percent of patients who scored this item correctly), and an item to group total correlation for each item. These data can be reported when describing the use of the test. This test is not recommended for the evaluation of self-management education programs because the items have not been matched to the particular educational content of the program. Educators wishing to do program evaluation may use some of the items on this test, but they should be certain that there is a good item-to-program content match. The 23-item test takes approximately 15 minutes to complete.
Select the document pertaining to the DKT you would like to download by clicking on the link:
DKT Modified True/False Version (PDF)
DKT Modified True/False Version with answers (PDF)
DKT Modified True/False Version Description (PDF)
List of articles concerning or using the DKT (Word)
List of articles concerning or using the DKT (PDF)
References
G. S. Collins, S. Mughal, A. H. Barnett, J. Fitzgerald and C. E. Lloyd. Short Report: Education and Psychological Aspects Modification and validation of the Revised Diabetes Knowledge Scale
Fitzgerald JT, Funnell MM, Anderson RM, Nwankwo R, Stansfield RB, Piatt GA. Validation of the Revised Brief Diabetes Knowledge Test (DKT2). The Diabetes Educator. 2016;42(2):178-187. doi:10.1177/0145721715624968.
Diabetes Attitude Scale - (DAS-3)
The Diabetes Attitude Scale can be used with both people with diabetes and health care professionals as a measure of general diabetes related attitudes. Information about the scoring and psychometric properties of this scale is also available here.
Select the document pertaining to the DKT you would like to download by clicking on the link:
Diabetes Attitude Scale - DAS-3 (Word)
Diabetes Attitude Scale - DAS-3 (PDF)
Diabetes Attitude Scale - 3 Formulae (Word)
Diabetes Attitude Scale - 3 Formulae (PDF)
List of articles using the DAS (Word)
List of articles using the DAS (PDF)
Diabetes Empowerment Scale (DES and DES-SF)
In 2000 we developed the Diabetes Empowerment Scale (DES) to measure the psychosocial self-efficacy of people with diabetes. The original questionnaire contained 37 items representing 8 conceptual dimensions (i.e. assessing the need for change; developing a plan; overcoming barriers; asking for support; supporting oneself; coping with emotion; motivating oneself; and making diabetes care choices appropriate for one's priorities and circumstances). Using factor analyses the questionnaire was reduced to the current 28-item DES alpha= 0.96 containing three subscales. (1) The three subscales are: 1) managing the psychosocial aspects of diabetes with 9 items, alpha= 0.93; 2) assessing dissatisfaction and readiness to change with 9 items alpha = 0.81; and 3) setting and achieving goals with 10 items, alpha = 0.91. In addition to providing an overall assessment of diabetes related psychosocial self-efficacy the three subscales of the DES allow for an examination of its underlying components.
In order to allow for a brief overall assessment of diabetes related psychosocial self-efficacy, we developed an eight item short form of the DES (the DES-SF). The DES-SF was created by choosing the item from the (remaining 28 items appeared in the published article but it is an error. It should say the original 37 items. This is a typographical error (ours) but it does not affect any of the psychometric data found in this article) items with highest item to subscale correlation from each of the original eight conceptual domains. The reliability of the DES-SF using the original data set was alpha = 0.85. We have subsequently administered the DES-SF to 229 subjects in a new study. The reliability of the DES-SF using the data from the new sample was alpha = 0.84. The content validity of the DES-SF was supported in the new study by the fact that both DES-SF scores and HbA1c levels changed in a positive direction after the 229 subjects completed a six-week problem based patient education program (2). The change in DES-SF scores and HbA1c levels were not correlated suggesting that these two measures vary independently.
These data provide preliminary evidence that the DES-SF is a valid and reliable measure of overall diabetes-related psychosocial self-efficacy.
References
1) Anderson RM, Funnell MM, Fitzgerald JT, Marrero DG: The diabetes empowerment scale: a measure of psychosocial self-efficacy. Diabetes Care 23:739-743, 2000
2) Anderson RM, Funnell MM, Nwankwo R, Gillard ML, Fitzgerald JT, Oh M: Evaluation of a problem-based, culturally specific, patient education program for African Americans with diabetes. Diabetes 50(Suppl. 2): A195, 2001
3) Anderson RM, Fitzgerald JT, Gruppen LD, Funnell MM, Oh MS: The diabetes empowerment scale-short form (DES-SF). Diabetes Care 26:1641-1643, 2003
Select the document pertaining to the DES you would like to download by clicking on the link:
DES - Long Form in English (Word)
DES - Long Form in English (PDF)
DES - Long Form in Spanish (Word)
DES - Long Form in Spanish (PDF)
DES - Short Form in English (Word)
DES - Short Form in English (PDF)
DES - Short Form in Spanish (Word)
DES - Short Form in Spanish (PDF)
Diabetes Empowerment Scale (DES) Scoring Key (Word)
Diabetes Empowerment Scale (DES) Scoring Key (PDF)
List of articles concerning or using the DES (Word)
List of articles concerning or using the DES (PDF)
Diabetes Semantic Differential Scales (DSDS)
Personal Attitudes of Diabetes Questionnaire (Word)
Personal Attitudes of Diabetes Questionnaire (PDF)
Personal Attitudes of Diabetes Questionnaire For Health Professionals (Word)
Personal Attitudes of Diabetes Questionnaire For Health Professionals (PDF)
References
Fitzgerald JT, Stansfield RB, Tang T, et al. Patient and Provider Perceptions of Diabetes: Measuring and evaluating differences. Patient education and counseling. 2008;70(1):118-125. doi:10.1016/j.pec.2007.09.005.
Tang TS, Stansfield RB, Oh M, Anderson RM, Fitzgerald JT. Patient–provider perceptions of diabetes and its impact on self-management: a comparison of African-American and White patients. Diabetic Medicine Diabetic Med. 2008;25(3):341-348. doi:10.1111/j.1464-5491.2007.02371.x.
Michigan Neuropathy Screening Instrument (MNSI)
The Michigan Neuropathy Screening Instrument (MNSI) is designed to screen for the presence of diabetic neuropathy. The MNSI is designed to be used in an outpatient setting by primary care or other providers. The first part of the screening instrument consists of 15 self-administered "yes or no" questions on foot sensation including pain, numbness and temperature sensitivity. A higher score (out of a maximum of 13 points) indicates more neuropathic symptoms.
The questions were chosen from among those in the Neuropathy Screening Profile of Peter Dyck that showed the highest degree of specificity and sensitivity for diabetic neuropathy among normal subjects and those with a variety of neuromuscular disorders (Neurology, 36:1300-1308, 1986).
The second part of the MNSI is a brief physical examination involving 1) inspection of the feet for deformities, dry skin, hair or nail abnormalities, callous or infection, 2) semi-quantitative assessment of vibration sensation at the dorsum of the great toe, 3) grading of ankle reflexes and 4) monofilament testing. Patients screening positive on the clinical portion of the MNSI (greater than 2 points on a 10 point scale) are considered neuropathic and referred for further evaluation.
Select the document pertaining to the MNSI you would like to download by clicking on the link: