By clicking "agree" below, you are e-signing this form and agree to the following:
I have read this information and have had time to consider whether to take part in this study. I understand that my participation is voluntary (it is my choice) and that I am free to withdraw from the research study at any time without disadvantage. I agree that the data can be used in the publication of scientific and research work. I agree that the information collected in this study will be stored in a protected archive where it may be available for future research. I understand that by authorizing the use of my personal data obtained in this survey, data privacy laws might not apply or no longer protect my information. I have read this consent form. I understand that I can refuse to participate in this project. I have taken time to think carefully about my decision to participate. I freely consent to share my data with this research project.
* must provide value
I have read the above information and I agree to participate
I am not interested
I am 18 years old or older* must provide value
Yes
No
In this survey, we will be asking about your out-of-pocket costs. We will ask you to select the currency you use to calculate costs. Out-of-pocket costs are the amount you pay from your own funds, including any taxes, fees, or other charges. For more definitions, visit our Glossary . Please complete a separate survey for each person in your household with type 1 diabetes. If completing on behalf of someone with T1D, note that references to "you/your" refer to the person with T1D.
What is your connection to type 1 diabetes?
* must provide value
I have type 1 diabetes
My child has type 1 diabetes
My spouse/partner/significant other has type 1 diabetes
I am a medical professional completing survey on behalf of a specific patient with type 1 diabetes
Prefer not to answer
If completing on behalf of someone with T1D, note that references to "you/your" refer to the person with T1D
What is your gender?* must provide value
Male
Female
Non-binary
Other
Prefer not to answer
If other, please specify
Do you identify as transgender?* must provide value
Yes
No
Prefer not to answer
What country do you live in? * must provide value
Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burma Burundi Cabo Verde Cambodia Cameroon Canada Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Costa Rica Cote d'lvoire Croatia Cuba Curacao Cyprus Czechia Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia, The Georgia Germany Ghana Greece Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States of America Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Zambia Zimbabwe
The option "
Which of these do you identify with? (Choose all that apply)* must provide value
Asian
Black/African/African American
Hispanic/Latino/Mestizo
Indigenous
Middle Eastern/North African
White/Caucasian
Other
Prefer not to answer
If other race, please specify:
What currency do you use?* must provide value
Australian Dollar (AUD)
Bosnia-Herzegovina Convertible Marka (BAM)
Canadian Dollar (CAD)
Chinese Renminbi (CNH)
Costa Rican Colón (CRC)
Euro (EUR)
Ghanaian Cedi (GHC)
Hong Kong Dollar (HKD)
Indian Rupee (INR)
Israeli New Shekel (ILS)
Japanese Yen (JPY)
Lebanese Pound (LBP)
Mexican Peso (MXN)
New Zealand Dollar (NZD)
Pakistani Rupee (PKR)
Panamanian Balboa (PAB)
Pound Sterling (GBP)
Swedish Krona (SEK)
Swiss Franc (CHF)
Tanzanian Shilling (TSH)
US Dollar (USD)
Zimbabwe Dollar (ZWD)
Your Currency
If your currency, please specify* must provide value
If selecting "Your Currency", please write your currency in the text box or we cannot calcuate your costs.
Do you have health coverage that covers the cost of your diabetes medication and supplies? * must provide value
No, there is no coverage for any of my costs
Yes, there is health coverage for some of my costs
Yes, there is health coverage for all of my costs (so I do not pay anything out of pocket)
Prefer not to answer
The option "
Do you receive any help to pay for your insulin, diabetes supplies, or care? * must provide value
No
Yes, support from family and friends
Yes, charities/religious/non-profit programs
Yes, donations (including online platforms like GoFundMe)
Yes, government assistance/benefit programs
Yes, pharmaceutical company assistance programs
Other
Prefer not to answer
If other, please describe
The option "
In the past year, have you had to do any of the following to pay for your out-of-pocket costs for your medication and/or supplies? (Choose all that apply)* must provide value
None of these
Use savings
Borrowed money
Sold assets
Other
Prefer not to answer
If other, please describe
The option "
Has the COVID-19 pandemic affected your access to insulin and diabetes supplies?* must provide value
No change
Access to supplies have been delayed or disrupted
Access to insulin has been delayed or disrupted
Prices have gone up
Prices have gone down
Unsure
Prefer not to answer
The option "
In what form do you get your insulin?
* must provide value
Insulin vials
Insulin pens
Inhaled insulin
Other
Prefer not to answer
If other, please specify
The option "
How do you administer the insulin? * must provide value
Syringes
Pens with pen needles
Insulin pump
Other
Prefer not to answer
If other, please specify
How much do you pay in ______ for a 1 month supply of pen needles and/or syringes?
The option "
Please select all insulins you currently use. * must provide value
Humalog U-100
Humalog U-200
Novolog/Novorapid
Apidra
Admelog
Lyumjev
Humulin
Novolin (Regular)
Fiasp
Velosulin
Lantus/ Toujeo
Levemir
Tresiba U-100
Tresiba U-200
Basaglar
NPH
Humulin 70/30
Humulin 50/50
Humalog 75/25
Novolin 70/30
Novolog 70/30
Mixtard
Rezvoglar
Afrezza
Semglee
Other
Prefer not to answer
If other, please list
How many vials of short-acting insulin (e.g. Humalog, Novolog/Novorapid, Apidra, Humulin, Novolin/Regular, Velosulin, Fiasp, Admelog, or Lyumjev) do you typically use per month?* must provide value
1
2
3
4
5
6
7
8+
Prefer not to answer
How many pens of short-acting insulin (e.g. Humalog, Novolog/Novorapid, Apidra, Humulin, Novolin/Regular, Velosulin, Fiasp, Admelog, or Lyumjev) do you typically use per month?* must provide value
1
2
3
4
5
6
7
8+
Prefer not to answer
How much do you pay out of pocket in ______ for a 1 month supply of short-acting insulin (e.g. Humalog, Novolog/Novorapid, Apidra, Humulin, Novolin/Regular, Velosulin, Fiasp, Admelog, or Lyumjev)?
Number only
How many vials of intermediate or long-acting insulin (e.g. Lantus/Toujeo, Levemir, Tresiba, Basaglar, NPH, Semglee, or Rezvoglar) do you typically use per month?* must provide value
1
2
3
4
5
6
7
8+
Prefer not to answer
How many pens of intermediate or long-acting insulin (e.g. Lantus/Toujeo, Levemir, Tresiba, Basaglar, NPH, Semglee, or Rezvoglar) do you typically use per month?* must provide value
1
2
3
4
5
6
7
8+
Prefer not to answer
How much do you pay out of pocket in ______ for a 1 month supply of intermediate or long-acting insulin (e.g. Lantus/Toujeo, Levemir, Tresiba, Basaglar, NPH, Semglee, or Rezvoglar)?
Number only
How many vials of mixed insulin (e.g. Humulin 70/30, Humulin 50/50, Humalog 75/25, Novolin 70/30, Mixtard or Novolog 70/30) do you typically use per month?* must provide value
1
2
3
4
5
6
7
8+
Prefer not to answer
How many pens of mixed insulin (e.g. Humulin 70/30, Humulin 50/50, Humalog 75/25, Novolin 70/30, Mixtard or Novolog 70/30) do you typically use per month?* must provide value
1
2
3
4
5
6
7
8+
Prefer not to answer
How much do you pay out of pocket in ______ for a 1 month supply of mixed insulin (e.g. Humulin 70/30, Humulin 50/50, Humalog 75/25, Novolin 70/30, Mixtard or Novolog 70/30)?
Number only
How many vials of other insulin type do you typically use per month?* must provide value
1
2
3
4
5
6
7
8+
Prefer not to answer
How many pens of other insulin type do you typically use per month?* must provide value
1
2
3
4
5
6
7
8+
Prefer not to answer
How much do you pay out of pocket in ______ for a 1 month supply of other insulin type?
Number only
How often do you have to ration or NOT give yourself insulin due to cost? * must provide value
Never
At least once per year
At least once per month
At least once per week
Every day
Prefer not to answer
What type of insulin pump do you use? * must provide value
Animas
Accu-Check
Asante
Medtronic
Sooil
Tandem t:slim
Omnipod
Other
Prefer not to answer
If other, pump type please list
How much did you pay out of pocket in ______ for your ______ pump?
Number only
How much do you pay out of pocket in ______ for a 1 month supply of insulin pump supplies?
Number only
What brand of blood testing strips do you primarily use? * must provide value
None
OneTouch
Accu-Check
Abbott Freestyle
Ascensia (Bayer)
Precision
True track
True test
Sanofi BG star
Subscription based services (e.g. One Drop or Good Glucose)
Other
Prefer not to answer
If other, please list
Approximately how many test strips do you use per month?
Number only
How much do you pay out of pocket in ______ for a 1 month supply of blood glucose testing strips?
Number only
Do you use a continuous glucose monitor/Flash Glucose Monitoring devices (CGM)? * must provide value
No
Yes, Dexcom
Yes, Medtronic
Yes, Freestyle Libre
Yes, other
Prefer not to answer
If other, please list
How much do you pay out of pocket in ______ for a 1 month supply of CGM/Flash Glucose Monitoring supplies?
Number only
How often do you NOT test your blood sugar due to lack of strips or CGM supplies?* must provide value
Never
At least once per year
At least once per month
At least once per week
Every day
Prefer not to answer
Do you use or keep a glucagon emergency injection or nasal spray (Baqsimi) for hypoglycemia (low blood sugar)?* must provide value
Yes, Glucagon
Yes, nasal spray (Baqsimi)
No
Prefer not to answer
The option "
You answered that you do not use or keep a glucagon or nasal spray with you. Why not? * must provide value
It is too expensive
It is not available where I live
I did not know it exists
I do not know how to use it
I do not want to keep it with me
I do not feel that I need it
Other
Prefer not to answer
If other, please list
How much do you pay out of pocket in ______ for a glucagon emergency shot or nasal spray?
Number only
Do you use or keep ketone strips with you?* must provide value
No
Yes, urine strips
Yes, blood strips
Prefer not to answer
The option "
You answered that you do not use or keep ketone strips with you. Why not?* must provide value
It is too expensive
It is not available where I live
I did not know it exists
I do not know how to use it
I do not want to keep it with me
I do not feel that I need it
Other
Prefer not to answer
If other, please describe
How much do you pay out of pocket in ______ for one container of ketone test strips?
Number only
The number below is the total sum in ______ of all monthly out-of-pocket costs you've entered related to your diabetes supplies.
View equation
How much do you pay in ______ annually for medical/doctor visits related to diabetes? This may be in the form of a "copay," if you have health coverage.
Number only
How much do you pay in ______ per month for your health coverage? You might know this as a 'premium.'
Number only
If comfortable, please share your total average monthly household expenses other than diabetes costs (i.e. rent/mortgage, utilities, food, leisure activities, clothing, etc).
Number only
If you could tell your government or people in power one thing, what would you tell them?
If you would like to share more information about life with diabetes in your country, email us at contact@t1international.com .
Working...