Digital Diabetes Prevention Program Interest Form WorkWell NYC is committed to supporting City employees in maintaining healthy, active lifestyles at work, at home and beyond, as you work to maintain a vibrant, safe and thriving city. Please fill in your information below to determine your eligibility and to receive more information about an upcoming cohort of the Digital Diabetes Prevention Program. Your responses are voluntary and confidential. Thank you! Question Title * 1. Please provide the following information: First and Last Name Email Address Question Title * 2. Please select your agency 311 ACS ACTUARY BIC BOC BOE BP-All CCHR CCRB CFB CLERK COIB COMPTROLLER COUNCIL Culturals CUNY DA-All DCA DCAS DCLA DCP DDC DEP DFTA DOB DOC DOE DOF DOHMH DOHMH-OCME DOI DOITT DOP DORIS DOT DSNY DSS / HRA / DHS DYCD EEPC FDNY FISA/OPA FIT H+H HPD IBO LAW Libraries LPC Mayor's Office MOCS MWFA NYCCSC NYCEM NYCERS NYCHA NYCPPF NYCTAX NYPD OATH OCB OLR OMB OSNP PA PARKS PUBADMIN SBS SCA TLC TRS Other (please specify) Question Title * 3. How do you describe yourself? As a man As a woman As a transgender man or woman As gender non-conforming Another gender identity Prefer not to answer Question Title * 4. Have you been told by a health care provider that you have pre-diabetes? Yes No I'm not sure Other (please specify) Question Title * 5. Did you score 9 or higher on the CDC Risk Test? If you haven't taken the test yet, you can take it here: https://www.cdc.gov/prediabetes/takethetest/ Yes No Question Title * 6. If you are a woman, have you ever been told by a health care provider that you had Gestational Diabetes Mellitus (GDM) during pregnancy? Yes No N/A (If you are a male, please select this answer) Question Title * 7. The Digital DPP sessions will be delivered fully online. What days work best to attend online DPP sessions? Monday Tuesday Wednesday Thursday Friday Question Title * 8. Please select the time slot that would work best for you to attend online DPP sessions. Please note that sessions are 1 hour long in duration. Morning (10am-12pm) Lunchtime (12pm-2pm) Afternoon (2pm-5pm) Other (please specify) Question Title * 9. Do you have any accessibility needs for this program that WorkWell NYC can help support (e.g. captioning, documents in accessible and/or alternate formats, etc)? Yes No Not Sure Thank you for your interest! WorkWell NYC will follow up with more information about the upcoming Digital Diabetes Prevention Program. To learn more about WorkWell NYC programs, visit nyc.gov/workwellnyc. Join the WorkWell NYC mailing list and be the first to know about upcoming health and wellness programs at your agency! Sign up here. Done