Diabetes Toolbox Feedback and Action Form

Tell us what you think! Your comments are important and we appreciate you taking time to complete the form below. After you successfully submit your feedback, a thank you page will appear.

Please include your e-mail address if you’d like to know when the Diabetes Toolbox is updated. We respect your privacy and will not sell, give or share your information with others.

Do you have a question about the Diabetes Toolbox? Please contact Mary Borland ; (608.210.6640)

Thanks in advance for sharing your feedback and plans with us.

1. Why did you visit the Diabetes Toolbox?
Please check all that apply.
	Learn more about diabetes
	Find materials to share with my company's management
	Find materials to use with my company's employees and/or their dependents
	Find information to help a family member, a friend or myself
	Other:

2. Did the Toolbox have the information you needed?
	Yes
	No

What information could be added?

3. What actions will you pursue to promote early detection, prevention and control of diabetes?
Please check all that apply.
	Share information with my company's management
	Hold an employee education session or lunch and learn
	Include information in our company's newsletter
	Have information available at a health fair
	Change our organizational policies and work environment
	Other:

4. What did you like most about the Diabetes Toolbox? What did you like least?
Your type of organization:
Please check one.

	Employer
	Health care
	Health plan/insurer
	Insurance agent or consultant
	Individual or personal interest
	Other:

Optional:
Your first name:
Your last name:
Your organization's name:
Your title:
Your phone:
Your e-mail address: