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Affiliate Forms

Affiliate Forms Due: Friday, February 26th, 2021 
 
Form 1: 
2021 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 2021 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 2020
    • 8 CDAPP Sweet Success trainings (Training Module or Archived Webinar) for all NEW staff seeing patients in the calendar year 2020
  • 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 2019 that carried over to 2020 by diabetes type (1/2/GDM).
  • Aggregate Data of clients seen in 2020 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

CDAPP Sweet Success Affiliate Application Form: Please Download and Submit to the Resource & Training Center (cdapp@perinatalnetwork.org)

CDAPP SS Affiliate Application
 

Example Data Form: If you wish to collect your own data on your patients, here is a sample data collection form for your use.

Data Form

 

 

 

How to Contact Us

CDAPP Sweet Success Resource & Training Center
Office line: 714-921-9755

email CDAPP Sweet Success (cdapp@perinatalnetwork.org)

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

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