Please list the Primary CDAPP Sweet Success Affiliate site name that you are
completing this Site Survey for.
1. Primary CDAPP Sweet Success Affiliate Name: Click here to enter text.
2. Have you been a CDAPP Sweet Success Affiliate in the past?
☐ Yes
☐ No
3. Are you completing the survey for more than (1) site?
☐ Yes
☐ No
4. If you answered “yes” to question 3, please list all additional sites that you are
completing this survey for. Leave rows blank if they do not pertain to you.
Name of Additional Satellite: Click here to enter text.
Name of Additional Satellite: Click here to enter text.
Name of Additional Satellite: Click here to enter text.
Name of Additional Satellite: Click here to enter text.
Name of Additional Satellite: Click here to enter text.
Name of Additional Satellite: Click here to enter text.
Name of Additional Satellite: Click here to enter text.
Name of Additional Satellite: Click here to enter text.
Name of Additional Satellite: Click here to enter text.
Name of Additional Satellite: Click here to enter text.
Name of Additional Satellite: Click here to enter text.
Name of Additional Satellite: Click here to enter text.
Name of Additional Satellite: Click here to enter text.
Name of Additional Satellite: Click here to enter text.
Name of Additional Satellite: Click here to enter text.
Name of Additional Satellite: Click here to enter text.
4. Affiliate Medical Director Name: Click here to enter text.
5. Affiliate Address:
Street Address + Suite, Building, or Room Number: Click here to enter text.
City: Click here to enter text.
Zip Code: Click here to enter text.
6. Please view your Affiliate Site(s) on our Affiliate Locator Online and tell us if
you would like anything altered or added (e.g. phone number, website added,
address change). Answer only the fields that apply and disregard this question if
you are a new Affiliate.
Change my Affiliate or Satellite Name to: Click here to enter text.
Change my Phone Number to: Click here to enter text.
Change my Affiliate Address to: Click here to enter text.
Add an email: Click here to enter text.
Add a Website: Click here to enter text.
Other (please type additional comments): Click here to enter text.
As a reminder, the staff education requirement is:
8 webinars per calendar year for new staff
4 webinars per calendar year for continuing staff
If you are a new Affiliate filling out a Site Survey for the first time, then all staff
seeing patients must have completed 8 webinars this past calendar year.
1. Lead Staff Person Info:
Name: Click here to enter text.
Credential (RN, RD, BMS, MD, etc.): Click here to enter text.
License #: Click here to enter text.
Email: Click here to enter text.
Direct Line: Click here to enter text.
Best way to contact Lead Staff Person:
☐ Email
☐ Phone
Lead Staff Person’s Completed Webinars (Check all that apply):
☐Recorded Webinar Found in the Archived Section of the CDAPP Sweet Success Website Previous to July 2014
☐ July 30, 2014: GDM Diagnosis and Blood Glucose Targets; Presenter: Leona Dang-Kilduff RN, MSN, CDE
☐ August 20, 2014: In-Hospital Care of Pregnant Women with Diabetes; Presenter: Leona Dang-Kilduff RN, MSN, CDE
☐ September 17, 2014: Improving Breastfeeding Outcomes: Our Collective Responsibility; Presenter: Karen Peters MBA,
RD, IBCLC
☐ October 15, 2014: Infants of Diabetic Mothers: Anticipatory Guidance for Families; Presenter: D. Lisa Bollman MSN,
RNC, CPHQ
☐ November 12, 2014: Glucose Controlling Medications; Presenter: Leona Dang-Kilduff RN, MSN, CDE
☐ December 10, 2014: Issues Related to Obesity and the Pregnant Diabetic Population; Presenter: Daniele Fedman MD,
FACOG
☐ January 21, 2015: Nutritional Management of Diabetes During Pregnancy; Presenter: Lily Nichols RDN, CDE
☐ February 18, 2015: Cultural and Psychosocial Competencies Relating to the Care of Women with GDM; Presenter:
Jacqueline Masullo LCSW
☐ March 18, 2015: Safety and Efficacy of Exercise During Pregnancy; Presenter: Lily Nichols RDN, CDE
☐ April 22, 2015: Managing Diabetes During Pregnancy and Postpartum; Presenter: Thomas R. Moore MD
☐ May 27, 2015: Tips & Techniques for Providing Effective Patient Education for Pregnant Women with Diabetes;
Presenter: D. Lisa Bollman MSN, RNC, CPHQ
☐ June 24, 2015: Preconception and Interconception Care for Preexisting Diabetes; Presenter: M. Lynn Yonekura MD,
FACOG
☐ July 29, 2015: California Diabetes and Pregnancy Program Sweet Success Update; Presenter: CDAPP Sweet Success
Resource & Training Center
☐ August 26, 2015: Breastfeeding, Diabetes and Medications; Presenter: Christine Bixby, MD
☐ September 23, 2015: Postpartum and Interconception Health for the GDM Population; Presenter: Kristin Castorino DO
☐ October 21, 2015: Nutritional Management of Gestational Diabetes During the Holidays; Presenters: Leah Blalock MS,
RD, CSP, CDE and Jill Nowak-Przygodzki RD, CDE
☐ November 18, 2015: Psychosocial Wellness for Pregnant Women with Diabetes during the Holidays; Presenter:
Jacqueline Masullo LCSW
☐ December 16, 2015: Oral Agents and Gestational Diabetes Mellitus; Presenter: Larry A. Cousins MD
2. Information for 2nd Staff Person:
Name: Click here to enter text.
Credential (RN, RD, BMS, MD, etc.): Click here to enter text.
License #: Click here to enter text.
Email: Click here to enter text.
2nd Staff Person’s Completed Webinars (Check all that apply):
☐Recorded Webinar Found in the Archived Section of the CDAPP Sweet Success Website Previous to July 2014
☐ July 30, 2014: GDM Diagnosis and Blood Glucose Targets; Presenter: Leona Dang-Kilduff RN, MSN, CDE
☐ August 20, 2014: In-Hospital Care of Pregnant Women with Diabetes; Presenter: Leona Dang-Kilduff RN, MSN, CDE
☐ September 17, 2014: Improving Breastfeeding Outcomes: Our Collective Responsibility; Presenter: Karen Peters MBA,
RD, IBCLC
☐ October 15, 2014: Infants of Diabetic Mothers: Anticipatory Guidance for Families; Presenter: D. Lisa Bollman MSN,
RNC, CPHQ
☐ November 12, 2014: Glucose Controlling Medications; Presenter: Leona Dang-Kilduff RN, MSN, CDE
☐ December 10, 2014: Issues Related to Obesity and the Pregnant Diabetic Population; Presenter: Daniele Fedman MD,
FACOG
☐ January 21, 2015: Nutritional Management of Diabetes During Pregnancy; Presenter: Lily Nichols RDN, CDE
☐ February 18, 2015: Cultural and Psychosocial Competencies Relating to the Care of Women with GDM; Presenter:
Jacqueline Masullo LCSW
☐ March 18, 2015: Safety and Efficacy of Exercise During Pregnancy; Presenter: Lily Nichols RDN, CDE
☐ April 22, 2015: Managing Diabetes During Pregnancy and Postpartum; Presenter: Thomas R. Moore MD
☐ May 27, 2015: Tips & Techniques for Providing Effective Patient Education for Pregnant Women with Diabetes;
Presenter: D. Lisa Bollman MSN, RNC, CPHQ
☐ June 24, 2015: Preconception and Interconception Care for Preexisting Diabetes; Presenter: M. Lynn Yonekura MD,
FACOG
☐ July 29, 2015: California Diabetes and Pregnancy Program Sweet Success Update; Presenter: CDAPP Sweet Success
Resource & Training Center
☐ August 26, 2015: Breastfeeding, Diabetes and Medications; Presenter: Christine Bixby, MD
☐ September 23, 2015: Postpartum and Interconception Health for the GDM Population; Presenter: Kristin Castorino DO
☐ October 21, 2015: Nutritional Management of Gestational Diabetes During the Holidays; Presenters: Leah Blalock MS,
RD, CSP, CDE and Jill Nowak-Przygodzki RD, CDE
☐ November 18, 2015: Psychosocial Wellness for Pregnant Women with Diabetes during the Holidays; Presenter:
Jacqueline Masullo LCSW
☐ December 16, 2015: Oral Agents and Gestational Diabetes Mellitus; Presenter: Larry A. Cousins MD
3. Information for 3rd Staff Person:
Name: Click here to enter text.
Credential (RN, RD, BMS, MD, etc.): Click here to enter text.
License #: Click here to enter text.
Email: Click here to enter text.
3rd Staff Person’s Completed Webinars (Check all that apply):
☐Recorded Webinar Found in the Archived Section of the CDAPP Sweet Success Website Previous to July 2014
☐ July 30, 2014: GDM Diagnosis and Blood Glucose Targets; Presenter: Leona Dang-Kilduff RN, MSN, CDE
☐ August 20, 2014: In-Hospital Care of Pregnant Women with Diabetes; Presenter: Leona Dang-Kilduff RN, MSN, CDE
☐ September 17, 2014: Improving Breastfeeding Outcomes: Our Collective Responsibility; Presenter: Karen Peters MBA,
RD, IBCLC
☐ October 15, 2014: Infants of Diabetic Mothers: Anticipatory Guidance for Families; Presenter: D. Lisa Bollman MSN,
RNC, CPHQ
☐ November 12, 2014: Glucose Controlling Medications; Presenter: Leona Dang-Kilduff RN, MSN, CDE
☐ December 10, 2014: Issues Related to Obesity and the Pregnant Diabetic Population; Presenter: Daniele Fedman MD,
FACOG
☐ January 21, 2015: Nutritional Management of Diabetes During Pregnancy; Presenter: Lily Nichols RDN, CDE
☐ February 18, 2015: Cultural and Psychosocial Competencies Relating to the Care of Women with GDM; Presenter:
Jacqueline Masullo LCSW
☐ March 18, 2015: Safety and Efficacy of Exercise During Pregnancy; Presenter: Lily Nichols RDN, CDE
☐ April 22, 2015: Managing Diabetes During Pregnancy and Postpartum; Presenter: Thomas R. Moore MD
☐ May 27, 2015: Tips & Techniques for Providing Effective Patient Education for Pregnant Women with Diabetes;
Presenter: D. Lisa Bollman MSN, RNC, CPHQ
☐ June 24, 2015: Preconception and Interconception Care for Preexisting Diabetes; Presenter: M. Lynn Yonekura MD,
FACOG
☐ July 29, 2015: California Diabetes and Pregnancy Program Sweet Success Update; Presenter: CDAPP Sweet Success
Resource & Training Center
☐ August 26, 2015: Breastfeeding, Diabetes and Medications; Presenter: Christine Bixby, MD
☐ September 23, 2015: Postpartum and Interconception Health for the GDM Population; Presenter: Kristin Castorino DO
☐ October 21, 2015: Nutritional Management of Gestational Diabetes During the Holidays; Presenters: Leah Blalock MS,
RD, CSP, CDE and Jill Nowak-Przygodzki RD, CDE
☐ November 18, 2015: Psychosocial Wellness for Pregnant Women with Diabetes during the Holidays; Presenter:
Jacqueline Masullo LCSW
☐ December 16, 2015: Oral Agents and Gestational Diabetes Mellitus; Presenter: Larry A. Cousins MD
4. Information for 4th Staff Person:
Name: Click here to enter text.
Credential (RN, RD, BMS, MD, etc.): Click here to enter text.
License #: Click here to enter text.
Email: Click here to enter text.
4th Staff Person’s Completed Webinars (Check all that apply):
☐Recorded Webinar Found in the Archived Section of the CDAPP Sweet Success Website Previous to July 2014
☐ July 30, 2014: GDM Diagnosis and Blood Glucose Targets; Presenter: Leona Dang-Kilduff RN, MSN, CDE
☐ August 20, 2014: In-Hospital Care of Pregnant Women with Diabetes; Presenter: Leona Dang-Kilduff RN, MSN, CDE
☐ September 17, 2014: Improving Breastfeeding Outcomes: Our Collective Responsibility; Presenter: Karen Peters MBA,
RD, IBCLC
☐ October 15, 2014: Infants of Diabetic Mothers: Anticipatory Guidance for Families; Presenter: D. Lisa Bollman MSN,
RNC, CPHQ
☐ November 12, 2014: Glucose Controlling Medications; Presenter: Leona Dang-Kilduff RN, MSN, CDE
☐ December 10, 2014: Issues Related to Obesity and the Pregnant Diabetic Population; Presenter: Daniele Fedman MD,
FACOG
☐ January 21, 2015: Nutritional Management of Diabetes During Pregnancy; Presenter: Lily Nichols RDN, CDE
☐ February 18, 2015: Cultural and Psychosocial Competencies Relating to the Care of Women with GDM; Presenter:
Jacqueline Masullo LCSW
☐ March 18, 2015: Safety and Efficacy of Exercise During Pregnancy; Presenter: Lily Nichols RDN, CDE
☐ April 22, 2015: Managing Diabetes During Pregnancy and Postpartum; Presenter: Thomas R. Moore MD
☐ May 27, 2015: Tips & Techniques for Providing Effective Patient Education for Pregnant Women with Diabetes;
Presenter: D. Lisa Bollman MSN, RNC, CPHQ
☐ June 24, 2015: Preconception and Interconception Care for Preexisting Diabetes; Presenter: M. Lynn Yonekura MD,
FACOG
☐ July 29, 2015: California Diabetes and Pregnancy Program Sweet Success Update; Presenter: CDAPP Sweet Success
Resource & Training Center
☐ August 26, 2015: Breastfeeding, Diabetes and Medications; Presenter: Christine Bixby, MD
☐ September 23, 2015: Postpartum and Interconception Health for the GDM Population; Presenter: Kristin Castorino DO
☐ October 21, 2015: Nutritional Management of Gestational Diabetes During the Holidays; Presenters: Leah Blalock MS,
RD, CSP, CDE and Jill Nowak-Przygodzki RD, CDE
☐ November 18, 2015: Psychosocial Wellness for Pregnant Women with Diabetes during the Holidays; Presenter:
Jacqueline Masullo LCSW
☐ December 16, 2015: Oral Agents and Gestational Diabetes Mellitus; Presenter: Larry A. Cousins MD
5. Information for 5th Staff Person:
Name: Click here to enter text.
Credential (RN, RD, BMS, MD, etc.): Click here to enter text.
License #: Click here to enter text.
Email: Click here to enter text.
5th Staff Person’s Completed Webinars (Check all that apply):
☐Recorded Webinar Found in the Archived Section of the CDAPP Sweet Success Website Previous to July 2014
☐ July 30, 2014: GDM Diagnosis and Blood Glucose Targets; Presenter: Leona Dang-Kilduff RN, MSN, CDE
☐ August 20, 2014: In-Hospital Care of Pregnant Women with Diabetes; Presenter: Leona Dang-Kilduff RN, MSN, CDE
☐ September 17, 2014: Improving Breastfeeding Outcomes: Our Collective Responsibility; Presenter: Karen Peters MBA,
RD, IBCLC
☐ October 15, 2014: Infants of Diabetic Mothers: Anticipatory Guidance for Families; Presenter: D. Lisa Bollman MSN,
RNC, CPHQ
☐ November 12, 2014: Glucose Controlling Medications; Presenter: Leona Dang-Kilduff RN, MSN, CDE
☐ December 10, 2014: Issues Related to Obesity and the Pregnant Diabetic Population; Presenter: Daniele Fedman MD,
FACOG
☐ January 21, 2015: Nutritional Management of Diabetes During Pregnancy; Presenter: Lily Nichols RDN, CDE
☐ February 18, 2015: Cultural and Psychosocial Competencies Relating to the Care of Women with GDM; Presenter:
Jacqueline Masullo LCSW
☐ March 18, 2015: Safety and Efficacy of Exercise During Pregnancy; Presenter: Lily Nichols RDN, CDE
☐ April 22, 2015: Managing Diabetes During Pregnancy and Postpartum; Presenter: Thomas R. Moore MD
☐ May 27, 2015: Tips & Techniques for Providing Effective Patient Education for Pregnant Women with Diabetes;
Presenter: D. Lisa Bollman MSN, RNC, CPHQ
☐ June 24, 2015: Preconception and Interconception Care for Preexisting Diabetes; Presenter: M. Lynn Yonekura MD,
FACOG
☐ July 29, 2015: California Diabetes and Pregnancy Program Sweet Success Update; Presenter: CDAPP Sweet Success
Resource & Training Center
☐ August 26, 2015: Breastfeeding, Diabetes and Medications; Presenter: Christine Bixby, MD
☐ September 23, 2015: Postpartum and Interconception Health for the GDM Population; Presenter: Kristin Castorino DO
☐ October 21, 2015: Nutritional Management of Gestational Diabetes During the Holidays; Presenters: Leah Blalock MS,
RD, CSP, CDE and Jill Nowak-Przygodzki RD, CDE
☐ November 18, 2015: Psychosocial Wellness for Pregnant Women with Diabetes during the Holidays; Presenter:
Jacqueline Masullo LCSW
☐ December 16, 2015: Oral Agents and Gestational Diabetes Mellitus; Presenter: Larry A. Cousins MD
If you have more than 5 Staff Persons who completed their education
requirement, please use the supplement Staff Education List found on our
website under Affiliates > Forms.
This section reflects annual data for the clients served in the 2015 calendar year.
Type of diabetes diagnosed at first CDAPP Sweet Success visit.
1. Clients seen in 2014 who carried over to 2015:
Total Number (sum of Type 1, Type 2, and GDM): Click here to enter text.
# of Type 1 Diabetes: Click here to enter text.
# of Type 2 Diabetes: Click here to enter text.
# of GDM: Click here to enter text.
2. New Clients seen only in 2015 (diagnosis at first CDAPP Sweet Success visit
occurring in 2015)
Total Number (sum of Type 1, Type 2, and GDM): Click here to enter text.
# of Type 1 Diabetes: Click here to enter text.
# of Type 2 Diabetes: Click here to enter text.
# of GDM: Click here to enter text.
3. Total Number of Clients seen in 2015
Overall Number (adding Total Number from question 1 and 2 together):
Click here to enter text.
Overall Number of Type 1 Diabetes Seen (add type 1's from question 1 and 2):
Click here to enter text.
Overall Number of Type 2 Diabetes Seen (add type 2's from question 1 and 2):
Click here to enter text.
Overall Number of GDM Seen (add GDM's from question 1 and 2):
Click here to enter text.
4. If you have any comments, suggestions or requests about CDAPP Sweet
Success, please add notes here: Click here to enter text.