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Affiliate Forms

Affiliate Forms Due: Thursday, January 31, 2019 
 
Form 1: 
2019 Memorandum of Understanding
- This document is the agreement between the Affiliate site and the California Diabetes and Pregnancy Program Sweet Success Resource & Training Center. It requires an electronic signature.

Download 2019 MOU

 

 

Form 2: 

Annual Affiliate Survey

Comprised of 3 Parts

Part 1 / 3: General Information

Part 2 / 3: Staff Education Requirement

  • The Staff Education Requirement for Affiliation is:
    • 4 CDAPP Sweet Success trainings (Training Module or Archived Webinar) for all staff seeing patients in the calendar year 2018
    • 8 CDAPP Sweet Success trainings (Training Module or Archived Webinar) for all NEW staff seeing patients in the calendar year 2018
  • Staff names, license numbers, contact information and trainings completed are reported in this section.
  • A CEU certificate does not need to be attached to this survey. The representative filling out this form for your Sweet Success Affiliate site must check the boxes of which CDAPP Sweet Success training modules or archived webinars each staff member seeing patients in your program completed.

Part 3 / 3: Site Specific Data & Questions

  • Aggregate Data of clients seen in 2017 that carried over to 2018 by diabetes type (1/2/GDM).
  • Aggregate Data of clients seen in 2018 by diabetes type (1/2/GDM).

 

Annual Affiliate Survey - Online Version

Annual Affiliate Survey - Word Document Version

  • ONLINE VERSION:
    • Can be filled out in more than one sitting if using the same computer.
    • Less time-consuming due to built in drop-downs.
  • WORD DOCUMENT VERSION:
    • Answers can be typed in and saved to your personal computer or printed and hand-written
    • If you have more than 5 staff persons to report their Staff Education, please use the Supplement Staff Education List in addition to the survey:

Download Supplement Staff Education List

 
 

Other Forms

If you would like to apply to become a CDAPP Sweet Success Affiliate, please fill out and submit the following:
CDAPP Sweet Success New Affiliate Application Form

If you wish to collect your own data on your patients, here is a sample data collection form for your use.
CDAPP Sweet Success Individual Affiliate Data Form (Word)

If you would like a quick summary of the types of client categories, services usually rendered, and CPT codes most often used when billing for these services, see the document below.  (This document is intended for use with non-CPSP payers.)
Example: Client, Length of Visit, Service, CPT Code





How to Contact Us

CDAPP Sweet Success Resource & Training Center
22875 Savi Ranch Parkway Suite I

Yorba Linda, CA 92887

O: 714-921-9755

email CDAPP Sweet Success

Funding is provided by Federal Title V Block Grant Funds through the California Department of Public Health (CDPH), Center for Family Health (CFH), Maternal, Child and Adolescent Health (MCAH) Division.