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U.S. Department of Health and Human Services
Special Diabetes Program for Indians (SDPI)

Diabetes Healthy Heart Project Toolkit

Appendices

Disclaimer Statement:

Most of the resources in the DP Toolkit Appendices (below) are examples of tools that were used by the 38 SDPI DP Initiative grant programs.

The following documents:

  • Were created to help implement diabetes prevention interventions in American Indian/Alaska Native communities
  • Have not been updated or edited from its original content, as they were developed for local use
  • Are time sensitive to the date and purpose for which they were created
  • May be outdated based on current clinical guidelines and practices

The Indian Health Service and the Division of Diabetes Treatment and Prevention make no representations as to accuracy, completeness, suitability, or validity of any information provided.

SDPI Healthy Heart Project HH Toolkit
 

Module 1: Getting Started - Appendix

Sharing Success Examples

 

Module 2: Identifying, Recruiting, and Retaining Participants - Appendix

Form Examples

Confidentiality Form Example
Medical Clearance Form Examples
Physical Exam Request Form Example
Participant Intake Form Example
Participant Referral to Dietitian Services Example

Screening/Assessment Examples

Screening and Assessment Tools Examples

Marketing Examples

Project Brochure Example
Program Recruitment Examples
Event Promotion Examples
Newsletter Example
 

Module 3: Implement a Healthy Heart Program

Policies and Guidelines Examples

Policy and Procedure Examples
Guideline Examples

Consent and Waiver Examples

Program Participation Consent Form Example
Waiver Example

Case Management Examples

Assessment Tools Examples
Tracking Forms and Progress Notes Examples
Letter to Patient Example
Enhancing Program Participation Examples
Motivational Interviewing Resource

Questionnaire and Data Collection Examples

Participant Questionnaire Data Collection Example
Program Feedback & Evaluation Examples

Patient Education Examples

Patient Education Handout Examples