U.S. DEPARTMENT OF 

Office of the Assistan

Road to Health Toolkit 

Evaluation Guide 

February 2012 

NDEP-125
 
i 

Road to Health Toolkit Evaluation Guide

Contents 

Overview and Purpose of the Road to Health Evaluation Guide .............................................................................................1
 

Types of Data to Be Collected.........................................................................................................................................................................1
 

Road to Health Participant Satisfaction Form.......................................................................................................................................2
 

How Will I Collect the Data?.............................................................................................................................................................................3
 

How Do I Use These Tools?...............................................................................................................................................................................7
 

Take Home Message.............................................................................................................................................................................................8
 

Links to NDEP Resources....................................................................................................................................................................................9
 

Road to Health Intervention Tracking Form: Individual Session...........................................................................................11
 

Road to Health Intervention Tracking Form: Group Session...................................................................................................13
 

Road to Health Participant Satisfaction Form....................................................................................................................................15
 

Thank You!................................................................................................................................................................................................................16
 

1 

Road to Health Toolkit Evaluation Guide

Your audience is the person or group 

of people with whom you most want 

to use the RTH Toolkit. Examples of 

audiences are: 

Overview and Purpose of the Road 

to Health Evaluation Guide 

Who will use this 

Evaluation Guide? 

This guide is for: 

•	 Community Health 

Workers, 

•	 Promotores de Salud, 

•	 Diabetes Educators, 

•	 Lay Health Workers, 

and 

•	 Health Educators 

...who use the 

Road to Health Toolkit. 

The National Diabetes Education Program (NDEP) created this guide for 

community health workers (CHWs), promotores de salud, diabetes educators, 

lay health workers, and health educators who want to know (1) how the Road 

to Health Toolkit is making a difference in the lives of their participants who 

are at risk for type 2 diabetes, and (2) how well they have conducted their 

own activities. 

For some, the idea of doing an evaluation can be scary, but it does not have 

to be. There are simple tools that you can use that can tell you: 

1. if you are using the toolkit with the audience you want to reach 	

2. if you want to change how you use the toolkit so that you can better meet 

participants’ needs, and/or 

3. if your participants are making the kinds of changes that will help them lower their risk for type 2 diabetes. 

This evaluation guide is not meant to teach you how to do an in-depth evaluation of how effective the Road to 

Health Toolkit is. Instead, the evaluation guide will give you easy-to-use tools that let you quickly collect some key 

pieces of data. These data will help you understand how well things are going, if you need to make any changes, 

and what those changes should be. If you, or your organization, are interested in learning more about evaluation, 

please contact Betsy Rodríguez, MSN, Deputy Director National Diabetes Education Program (bjr6@cdc.gov) for 

more information. 

Who is your audience? 

Types of Data to Be Collected 

Included in this guide are three forms that you can use to collect 

data to assess your use of the Road to Health Toolkit. These forms 

are called the Road to Health Intervention Tracking Form: 

Group Sessions, the Road to Health Intervention Tracking 

Form: Individual Sessions, and the Road to Health Participant 

Satisfaction Form.
 

•	 African Americans and Hispanics/ 

Latinos ages 50–70 who are at risk 

for type 2 diabetes 

•	 Hispanic/Latino and African 

American pregnant women who 


are at risk for gestational diabetes 


or had gestational diabetes in 

previous pregnancies 

•	 Family members or relatives who 

are at risk for type 2 diabetes	 

Road to Health Intervention Tracking Forms for 

Individual and Group Sessions 

These tracking forms contain two sets of questions. The first set of 

questions helps you keep track of those with whom you are using 

the toolkit. It also helps you keep track of how you are using the 

toolkit (e.g., the number of sessions, the length of each session, 


the topics covered in each session, and what parts of the toolkit 


were used during each session). 


It is important to think ahead of time 


about the people with whom you want 

to use the toolkit so you can make sure 

that your outreach efforts focus on 

those individuals.
 
2 

Road to Health Toolkit Evaluation Guide 

The first section in the forms is about the sessions, how they are delivered and what happens in each session. This is 

also known as process data. Good process data helps you know if you need to make changes in the way you are 

using the toolkit. This information can also be useful to share with your supervisor about the type of activities that 

you have been doing with your participants. 

The second set of questions will help you know if your participants are making progress toward the goals they have 

set for themselves. This information, known as outcome data, will tell you if participants have: 

•	 Made the recommended changes in their eating habits (making healthy food choices) 

•	 Increased their physical activity (moderate-intensity physical activity, for example: walking briskly, bicycling 

slower than 10 miles per hour, dancing, and general gardening) 

•	 Lost 5-7 percent of their body weight, if overweight or obese 

You should complete the form as soon as possible after the education session and before you conduct another 

education session. If you are working with one participant at a time, you will use the Road to Health Intervention 

Tracking Form: Individual Sessions. If you are working with two or more people at the same time, you will use 

the Road to Health Intervention Tracking Form: Group Sessions. 

Recommended 

Changes in Making 

Healthy Food Choices 

RTH Toolkit User’s Guide, 

page 8 

•	 Eat a variety of foods that 

are low in fat 

•	 Reduce the number of 

calories eaten per day 

Recommendations for 

Physical Activity 

RTH Toolkit User’s Guide, 

page 8 

•	 Get at least 30 minutes 

of moderate-intensity 

physical activity five days 

a week. This could be 

brisk walking, yard work, 

and actively playing with 

children. 

Recommendations for 

Weight Loss 

RTH Toolkit User’s Guide, 

page 8 

•	 Lose 5-7 percent of 

current weight, if 

overweight—that’s 10 to 

14 pounds (4.5 to 6.3 kg) 

for a 200 pound (90.6 kg) 

person. 

Road to Health Participant Satisfaction Form 

Participants can use this form to let you know how well the session went. This information is very important 

because it gives you an idea of which activities work best for your participants. This data can also help you know 

which activities or parts of the toolkit do not work as well. Based on this feedback, you may decide to change the 

activity to make it more effective. This type of information is another form of outcome data. 

The Road to Health Participant Satisfaction Form should be given to participants at the end of each session. You 

can also summarize the information from the participant satisfaction form to complete some of the “Demographic 

Information” questions found on the Road to Health Intervention Tracking Form: Group Sessions. 
Road to Health Toolkit Evaluation Guide

 

Your Name: 

Mary Smith 

Participant Name: 

Ray Williams 

Date: 

November 19, 2010 

Location: St. Peter’s Health Care Center, Houston, TX Length of Session: 45 min 

Demographic Information 

Race (check at least one): Gender: Age Range: 

 Black/African American  Male  18 – 25 years 

 Hispanic/Latino  Female  26 – 35 years 

 American Indian or Alaska Native  36 – 45 years 

 Asian  46 – 55 years 

 Native Hawaiian or Pacific Islander 

 56 – 65 years 

 White  65+ years 

 Other: ______________________ 

Marital Status: Number of Children: Diagnosis: 

 Single, never married 3  Has diabetes 

 Married  Has gestational diabetes 

 Divorced 

 Widowed 

  Has pre-diabetes1 

 At risk for diabetes (see pg. 3 of the 

RTH Flipchart for the risk factors for 

type 2 diabetes) 

 Has a family member with diabetes 



How Will I Collect the Data?
 

The tracking forms and the Road to Health Participant Satisfaction Form are the main data collection tools. 

•	 The tracking forms are to be completed by you— 

•	 The Road To Health Participant Satisfaction Form should be completed by your participants. 

It is important that both tools be completed at the end of a session and before another session begins. The 


information you collect will address both the process and outcome questions listed below. 


This section will explain how to use the data collection tools.
 

•	 Are you reaching your intended audience? (Process data) 

—	 In the Road to Health Intervention Tracking Form: Individual Session, there is an area for you to write 

information about the participant. Here is an example of how the Road to Health Intervention Tracking 

Form: Individual Session can be filled out. 

1

 Prediabetes. Pre-diabetes is a condition in which blood glucose levels are higher than normal but not high enough for a diagnosis of 

diabetes. Retrieved 9/13/2011 http://diabetes.niddk.nih.gov/dm/pubs/dictionary/pages/l-p.aspx#P 

3 
Road to Health Toolkit Evaluation Guide 

 

 

Your Name: 

Mary Smith 

Participant Names: 

Ana Smith 

Ray Williams

Angela Williams

Mary Thomas

Larry Doe

Ann Johnson 

Gail Washington

David Thompson 

Date: 

October 20, 2010 

Location: 

St. Peter’s Health Care Center, Houston, TX 

Length of Session: 

60 mins 

Demographic Information 

Number of Participants: 8 Average Number of Children per Participant: 4 

Race (check all that apply): Age Range (check all that apply): 

 Black/African American  18 – 25 years 

 Hispanic/Latino  26 – 35 years 

 American Indian or Alaska Native  36 – 45 years 

 Asian 

 Native Hawaiian or Pacific Islander 



 White 

 46 – 55 years 

 56 – 65 years 

 65+ years 







 Other: ______________________ 

Diagnosis: 

 Has diabetes. How many:__________ 

 Has gestational diabetes. How many:__________ 

 Has pre-diabetes. How many:__________ 

 2

Average Income (your best guess 

is fine): 

 Less than $20,000 

 $20,001 - $40,000 



 At risk for diabetes (see pg. 3 of the Flipchart). How many:__________ 

 Has a family member with diabetes. How many:__________ 

 3 

 6* 

 $40,001 - $60,000 

 $60,001+ 

— You will use a similar process for complete the Road to Health Intervention Tracking Form: Group 

Session. You may need to estimate about how many people fall under a category. 

*Notice that the total number in the “Diagnosis” section is greater than the number of participants (8). At times, you might find that 

your participant will fit into more than one category. For example, a person may be at risk for diabetes and have a family member who 

has diabetes. That person would be counted in both categories. 

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Road to Health Toolkit Evaluation Guide

Road to Health Toolkit Materials 

Road to Health Flipchart: Select any sections of the Road to Health Flipchart that you used in this session 

 Part 1: Type 2 Diabetes is 

Preventable and Losing Some 

Weight Can Help 

 

 Part 2: Making Healthy Food Choices  Part 3: Increasing Physical Activity 

Other Activities and Resources: Select any other Road to Health activities or resources that you used in this session 

 Activity 1: Portion Distortion 

 Activity 2: Food Detective I 

 Activity 3: Food Detective II 

 Activity 4: Community Kitchen 

 Activity 5: Sneak in Nutrition 

 Activity 6: Lunch Exchange 

 Activity 7: Community Water Log 

 Activity 8: The “Gross Value” of a Meal 

Deal 

 Activity 9: Supper Clubs 



 Activity 10: 10,000 Steps Club 

 Activity 11: A Journey of Two 

 Activity 12: Neighborhood 

Discovery 

 Activity 13: Community Garden 

 Activity 14: Train like a Super Star 

 Activity 15: PAWS 

 Activity 16: 3-on-3 

 Activity 17: Walk to Timbuktu 



 Movimiento por su Vida CD/DVD 

 Step by Step CD/DVD 

 RTH: Barriers to Being Active Quiz 

 RTH: City of Excuses Poster 

 RTH: Future Without Type 2 

Diabetes Poster 

 RTH: Reading Nutrition Labels 

Poster 

 RTH: Preventing Diabetes Step by 

Step - Floor Poster 

 RTH: Preventing Diabetes Step by 

Step - Wall Poster 

 RTH: Traffic Light Method Poster 

•	 How are you using the toolkit? ( Process data) 

—	 In this section, you will check off the topic areas that you discussed and the activities that you used for the 

session. The individual and group forms have the same sections. 

—	 Remember to answer the questions as completely as possible. 

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Road to Health Toolkit Evaluation Guide 

 

 

•	 How well did today’s session go? (Outcome data) 

—	 This question can be answered using data from the tracking forms and the Road to Health Participant 

Satisfaction Form. 

—	 On the Road to Health Participant Satisfaction Form, the participant will tell you how well the session 

went. 

—	 On the tracking forms, you will answer how well you thought the session went. 

How well did today’s session go? 

 Very well 



 Somewhat well 

 Neither well nor poor 

 Somewhat poor 

 Very poor 

What about today’s session went well? My participant said that he started 

reading nutrition labels, so he is doing better than last week. 

What about today’s session could be changed? I had all the materials prepared to 

do the Activity 13: Community Garden, from the RTH Activities Guide with 

my participant, but I found out that he has allergies, so he will have trouble 

breathing if we go outside for a long time. I will not do this activity with 

this participant again. 

•	 Are my participants changing their behavior in order to reduce the risk of type 2 diabetes (i.e., making 

healthy food choices, increasing physical activity, and losing weight)? (Outcome data) 

—	 This outcome question can be answered using questions from the RTH Intervention Tracking Forms (see 

example below) and the RTH Participant Satisfaction Form. 

Goal No progress Some progress Completed 

Controlling portion size 

Eating food with less fat 

Eating food with fewer calories 

Avoiding fast food value meals 

Reading nutrition labels 











6
 
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Road to Health Toolkit Evaluation Guide

How Do I Use These Tools? 

Remember that you know your participants’ needs best and you understand the most effective ways to deliver the 

RTH toolkit activities. You may not use all of the activities, so all of the questions on the data collection forms may 

not be useful to you. Instead of using the whole form, you may want to use just a few questions. If you are already 

using a different data collection tool, it may be most helpful to include questions from the tracking forms and the 

Road to Health Participant Satisfaction Form in that tool. 

If you have questions about how to use the data collection forms, here are some answers to common questions 

that might be helpful: 

Examples of ways you 

can summarize the data 

include: 

How often should I use the data collection forms? 

To collect the most useful data, it is important that you complete the 

forms immediately after each session with an individual or group. 

•	 “There were 2 men and 6 

women in class on August 

10, 2010.” 

How do I analyze the data?	 

There are several different ways to analyze the data. You can: 

•	 “Participant A has lost 2 lbs. 

since the last session.” •	 Review the data for each participant you’ve worked with to see how 

he or she has changed behaviors or weight over time 

•	 Review the data to see how the group’s behaviors have changed over time 

•	 If there is more than one CHW/Promotor in your organization, you can 

—	 compare your individual and group data with another CHW/Promotor, or 

—	 combine your data with another CHW/Promotor to see how effective the Road to Health Toolkit is at your 

organization. 

Examples of How to Use the Data 

Once you have used the forms to collect data about your participants and RTH activities, this information can help 

you decide how to address some of the challenges that you might have. Here are two scenarios that show you how 

you can use the data from the data collection forms to help your participants: 

Scenario 1 (Process data): 

You review your tracking forms for the last month and see that most of the people in your sessions already have 

diabetes. Before you started to use the toolkit you and your supervisor agreed that you really wanted to use it 

with people who are at risk for pre-diabetes. Your data is telling you that you are not reaching those people. 

What can you do? 

•	 You can talk with your supervisor about changing how you invite people to your sessions. 

•	 You can ask your current participants if they have any family members who might be interested in working 

with you but who have not been diagnosed. 

•	 You can reach out to a local physician or community health center to refer people who are at risk for diabetes 

to you. 
8 

Road to Health Toolkit Evaluation Guide 

Scenario 2 (Outcomes data): 

When you review the Road to Health Participant Satisfaction Forms, you learn that your participants enjoy 

the sessions and are reading nutrition labels when they go grocery shopping, but they are still not choosing 

healthier food options. 

What can you do? 

•	 You can ask your participants why they are not choosing healthier foods. 

•	 For people who are still unsure about what healthy options are, you can use: 

—	 Community Kitchen (Activity 4: Road to Health Toolkit’s Activities Guide, pg. 21), and 

—	 Lunch Exchange (Activity 6: Road to Health Toolkit’s Activities Guide, pg. 23) nutrition activities to review 

how to make healthy food choices. 

Take Home Message 

The resources in this guide are designed to support you in your evaluation efforts. For you to get the most out of 

evaluation, it should be relevant to you. We encourage you to take these materials and make them meaningful to 

you. If this is your first experience with evaluation, do not worry! It may seem scary at first, but it can ultimately help 

you improve the health of all your participants. 
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Road to Health Toolkit Evaluation Guide

Links to NDEP Resources 

For CHWs/Promotores interested in more RTH toolkit materials, we recommend the following resources: 

Road to Health Toolkit (PDFs in English and Spanish) 

Road to Health Toolkit - User’s Guide: 

http://ndep.nih.gov/media/road-to-health-toolkit-users-guide.pdf 

Road to Health Toolkit - Flipchart: 

http://ndep.nih.gov/media/road-to-health-toolkit-flipchart.pdf 

Road to Health Toolkit - Activities Guide: 

http://ndep.nih.gov/media/road-to-health-toolkit-activities-guide.pdf 

Road to Health Toolkit - Resources Guide: 

http://ndep.nih.gov/media/road-to-health-toolkit-resources-guide.pdf 

El camino hacia la buena salud - Guía del Usuario 

http://ndep.nih.gov/media/road-to-health-user-guide-spanish.pdf 

El camino hacia la buena salud - Rotafolio 

http://ndep.nih.gov/media/road-to-health-flipchart-spanish.pdf 

El camino hacia la buena salud - Guía de Actividades: 

http://ndep.nih.gov/media/road-to-health-activities-guide-spanish.pdf 

El camino hacia la buena salud - Guía de Recursos 

http://ndep.nih.gov/media/road-to-health-resource-guide-spanish.pdf 

Road to Health Training Support 

Road to Health Toolkit Training Guide (available in English and Spanish): 

http://ndep.nih.gov/media/road-to-health-training-guide.pdf 

Road to Health Toolkit Training Video/DVD (bilingual): 

http://ndep.nih.gov/media/road-to-health-dvd-booklet.pdf 

Road to Health Resources to Support Physical Activity 

Movimiento por su Vida CD/DVD 

http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=69 

Step by Step: Moving Towards Prevention of Type 2 Diabetes CD/DVD 

http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=95 
10 

Road to Health Toolkit Evaluation Guide 

Road to Health Toolkit Posters (These resources are available in Spanish at 

http://ndep.nih.gov/publications/PublicationDetail.aspx?PubId=166) 

Road to Health: Barriers to Being Active Quiz 

http://ndep.nih.gov/media/road-to-health-barriers-quiz.pdf 

Road to Health: City of Excuses Poster 

http://ndep.nih.gov/media/road-to-health-city-of-excuses.pdf 

Road to Health: Future Without Type 2 Diabetes Poster 

http://ndep.nih.gov/media/road-to-health-future-without-diabetes-poster.pdf 

Road to Health: Reading Nutrition Labels Poster 

http://ndep.nih.gov/media/road-to-health-nutrition-facts-labels-poster.pdf 

Road to Health: Preventing Diabetes Step by Step - Floor Poster 

http://ndep.nih.gov/media/road-to-health-step-by-step_floor_poster.pdf 

Road to Health: Preventing Diabetes Step by Step - Wall Poster 

http://ndep.nih.gov/media/road-to-health-step-by-step-poster.pdf 

Road to Health: Traffic Light Method Poster 

http://ndep.nih.gov/media/road-to-health-traffic-light-method-poster.pdf 

Evaluation Resources 

Centers for Disease Control and Prevention Framework for Program Evaluation 

http://www.cdc.gov/eval/framework/index.htm 

The Community Toolbox, Part J: Evaluating Community Programs and Initiatives (Chapters 36-39) 

http://ctb.ku.edu/en/tablecontents/index.aspx 

University of Arizona, Rural Health Office (2002). Community Health Worker Evaluation Toolkit, 

University of Arizona, Rural Health Office, El Paso Satellite, Suite 205, El Paso, Texas, 79902. 

https://apps.publichealth.arizona.edu/CHWToolkit/ 
Road to Health Toolkit Evaluation Guide

 

Road to Health Intervention Tracking Form: Individual Session
 

Instructions for Health Educators, Diabetes Educators, Community Health Workers, and Promotores de Salud: Please

complete this form after each education session or activity with the participant(s) using Road to Health Toolkit materials. 

Please check all that apply and answer each question completely. Keep the original copy for your personal records. 

Your Name: Participant Name: Date: 

Location: Length of Session: 

Demographic Information 

Race (check at least one): 

 Black/African American 

 Hispanic/Latino 

 American Indian or Alaska Native 

 Asian 

 Native Hawaiian or Pacific 

Islander 

 White 

 Other: ____________________ 

Gender: 

 Male 

 Female 

Age Range: 

 18 – 25 years 

 26 – 35 years 

 36 – 45 years 

 46 – 55 years 

 56 – 65 years 

 65+ years 

Marital Status: Number of Children: Diagnosis: 

 Single, never married  Has diabetes 

 Married  Has gestational diabetes 

 Divorced  Has pre-diabetes 

 Widowed  At risk for diabetes (see pg. 3 of 

the RTH Flipchart for the risk 

factors for type 2 diabetes) 

 Has a family member with 

diabetes 

Road to Health Toolkit Materials 

Road to Health Flipchart: Select any sections of the Road to Health Flipchart that you used in this session 

 Part 1: Type 2 Diabetes is 

Preventable and Losing Some 

Weight Can Help 

 Part 2: Making Healthy Food 

Choices 

 Part 3: Increasing Physical Activity 

Other Activities and Resources: Select any other Road to Health activities or resources that you used in this session 

 Activity 1: Portion Distortion  Activity 10: 10,000 Steps Club  Movimiento por su Vida CD/DVD 

 Activity 2: Food Detective I  Activity 11: A Journey of Two  Step by Step CD/DVD 

 Activity 3: Food Detective II  Activity 12: Neighborhood  RTH: Barriers to Being Active Quiz 

 Activity 4: Community Kitchen Discovery  RTH: City of Excuses Poster 

 Activity 5: Sneak in Nutrition  Activity 13: Community Garden  RTH: Future Without Type 2 

 Activity 6: Lunch Exchange  Activity 14: Train like a Super Star Diabetes Poster 

 Activity 7: Community Water Log 

 Activity 8: The “Gross Value” of a Meal 

Deal 

 Activity 15: PAWS 

 Activity 16: 3-on-3 

 Activity 17: Walk to Timbuktu 

 RTH: Reading Nutrition Labels 

Poster 

 RTH: Preventing Diabetes Step by 

Step - Floor Poster 

 Activity 9: Supper Clubs  RTH: Preventing Diabetes Step by 

Step - Wall Poster 

 RTH: Traffic Light Method Poster 

11
 
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Road to Health Toolkit Evaluation Guide 

1. How well did today’s session go? 

Very well 

Somewhat well 

Neither well nor poor 

Somewhat poor 

Very poor 

What about today’s session went well? 

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

What about today’s session could be changed? 

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

2. What goals did you set or discuss with your participant(s) today? (check all that apply) 

Controlling portion size 

Eating food with less fat 

Eating food with fewer calories 

Avoiding fast food value meals 

Reading nutrition labels 

Eating more servings of vegetables 

and fruits per day 

Drinking more water every day 

Drinking less non-diet juice or soda per day 

5–7 percent weight loss 

Increasing physical activity to 150 minutes per week 

Other (describe): __________________________ 

Other (describe): __________________________ 

3. How much progress do you think your participant(s) made toward each of those goals during the session? 

Goal No progress Some progress Completed 

Controlling portion size 

Eating food with less fat 

Eating food with fewer calories 

Avoiding fast food value meals 

Reading nutrition labels 

Eating more servings of vegetables and fruits per day 

Drinking more water every day 

Drinking less non-diet juice or soda per day 

5–7 percent weight loss 

Increasing physical activity to 150 minutes per week 

Other (describe): _____________________________________ 

Other (describe): _____________________________________ 

4. Any additional comments? 

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 
Road to Health Toolkit Evaluation Guide

 

Road to Health Intervention Tracking Form: Group Session
 

Instructions for Health Educators, Diabetes Educators, Community Health Workers, and Promotores de Salud: 

Please complete this form after each education session or activity with the participant(s) using Road to Health Toolkit 

materials. Please check all that apply and answer each question completely. Keep the original copy for your personal records. 

Your Name: Participant Names: 

Date: 

Location: Length of Session: 

Demographic Information 

Number of Participants: Average Number of Children per Participant: 

Race (check all that apply): Age Range (check all that apply): 

 Black/African American  18 – 25 years 

 Hispanic/Latino  26 – 35 years 

 American Indian or Alaska Native  36 – 45 years 

 Asian  46 – 55 years 

 Native Hawaiian or Pacific Islander  56 – 65 years 

 White  65+ years 

 Other: ______________________ 

Diagnosis: Average Income (your best guess is fine): 

 Has diabetes. How many:__________  Less than $20,000 

 Has gestational diabetes. How many:__________  $20,001 - $40,000 

 Has pre-diabetes. How many:__________  $40,001 - $60,000 

 At risk for diabetes (see pg. 3 of the Flipchart). How many:__________  $60,001+ 

 Has a family member with diabetes. How many:__________ 

Road to Health Toolkit Materials 

Road to Health Flipchart: Select any sections of the Road to Health Flipchart that you used in this session 

 Part 1: Type 2 Diabetes is 

Preventable and Losing Some 

Weight Can Help 

 Part 2: Making Healthy Food Choices  Part 3: Increasing Physical Activity 

Other Activities and Resources: Select any other Road to Health activities or resources that you used in this session 

 Activity 1: Portion Distortion  Activity 10: 10,000 Steps Club  Movimiento por su Vida CD/DVD 

 Activity 2: Food Detective I  Activity 11: A Journey of Two  Step by Step CD/DVD 

 Activity 3: Food Detective II  Activity 12: Neighborhood Discovery  RTH: Barriers to Being Active Quiz 

 Activity 4: Community Kitchen  Activity 13: Community Garden  RTH: City of Excuses Poster 

 Activity 5: Sneak in Nutrition  Activity 14: Train like a Super Star  RTH: Future Without Type 2 

Diabetes Poster  Activity 6: Lunch Exchange  Activity 15: PAWS 

 RTH: Reading Nutrition Labels  Activity 7: Community Water  Activity 16: 3-on-3 Poster Log  Activity 17: Walk to Timbuktu  RTH: Preventing Diabetes Step by  Activity 8: The “Gross Value” of a Step - Floor Poster Meal Deal 

 RTH: Preventing Diabetes Step by  Activity 9: Supper Clubs Step - Wall Poster 

 RTH: Traffic Light Method Poster 

13
 
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Road to Health Toolkit Evaluation Guide 

1. How well did today’s session go? 

Very well 

Somewhat well 

Neither well nor poor 

Somewhat poor 

Very poor 

What about today’s session went well? 

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

What about today’s session could be changed? 

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

2. What goals did you set or discuss with your participant(s) today? (check all that apply) 

Controlling portion size 

Eating food with less fat 

Eating food with fewer calories 

Avoiding fast food value meals 

Reading nutrition labels 

Eating more servings of vegetables 

and fruits per day 

Drinking more water every day 

Drinking less non-diet juice or soda per day 

5–7 percent weight loss 

Increasing physical activity to 150 minutes per week 

Other (describe): __________________________ 

Other (describe): __________________________ 

3. How much progress do you think your participant(s) made toward each of those goals during the session? 

Goal No progress Some progress Completed 

Controlling portion size 

Eating food with less fat 

Eating food with fewer calories 

Avoiding fast food value meals 

Reading nutrition labels 

Eating more servings of vegetables and fruits per day 

Drinking more water every day 

Drinking less non-diet juice or soda per day 

5–7 percent weight loss 

Increasing physical activity to 150 minutes per week 

Other (describe): _____________________________________ 

Other (describe): _____________________________________ 

4. Any additional comments? 

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 
15
 

Road to Health Toolkit Evaluation Guide

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

__________________________________________________________________________________________________ 

Very 

unlikely 

Somewhat 

unlikely Not sure Somewhat 

likely 

Very 

likely 

7. Choose foods that are low in calories and fat 

8. Control the portion size of my foods 

9. Lose 5-7 percent of my body weight 

10. Do physical activity or be physically active for 

at least 30 minutes, at least 5 days a week 

Road to Health Participant Satisfaction Form
 

We would like to hear your thoughts about today’s session. Please take a few minutes to tell us your thoughts. 

1. Overall, how do you think today’s session went? 

What You Know 

After today’s session, how much better do you understand the topics below: 

2. The information in nutrition labels 

Not better A little better Slightly better A lot better 

3. How much weight you need to lose in order 

to reduce your risk for diabetes 

4. Controlling the portion size of your food 

5. How to choose foods with less calories and fat 

6. How to be more physically active every day 

What You Do/What You Plan to Do 

After today’s session, how likely are you to do the following: 

How are we doing? 

11. Overall this session: 

 Helped me progress toward my goals 

 Did not help me progress toward my goals 

 I do not have goals set up 

12. What did you like most about this session? 

 The facilitator 

 Interacting with others/peer support 

 Length of session 

 The discussion topics 

 The materials/resources 

 Other (describe): ________________ 
16 

Road to Health Toolkit Evaluation Guide 

13. What would you change about this session? 

 Interacting with others/peer support 

 Length of session 

 The discussion topics 

 The materials/resources 

 Other (describe): _______________ 

Please tell us about you 

14. Have you ever been diagnosed with Type 2 Diabetes? 

 Yes 

 No, I have never been diagnosed 

 No, but my doctor told me that I have pre-diabetes 

 No, but I have been told that I am at risk for diabetes 

 No, but I have a family member with diabetes 

15. I believe I am: 

 Overweight 

 Underweight 

 At the right weight 

16. Weight (estimate) ____________ 

17. Number of days per week I do physical activity (e.g., brisk walking, aerobic exercise,2

 dancing, swimming, etc.) 

__________ 

a. Number of minutes I spend in physical activity on days when I am active ________ 

18. In what year where you born? ___________ 

19. Are you? 

 Male 

 Female 

20. Do you consider yourself (mark one or more)? 

 Black/African American 

 Hispanic/Latino 

 American Indian or Alaska Native 

 Asian 

 Native Hawaiian or Pacific Islander 

 White 

 Other: ______________________ 

Thank You!
 

2

 Aerobic physical activity. Activity in which the body’s large muscles move in a rhythmic manner for a sustained period of time. Aerobic 

activity, also called endurance activity, improves cardiorespiratory fitness. Examples include walking, running, swimming, and bicycling. 

Retrieved 9/13/2011 http://www.cdc.gov/physicalactivity/everyone/glossary/ 
U.S. DEPARTMENT OF 

Office of the Assistan

l l

The U.S. Department of Health and Human Services’ National Diabetes Education Program (NDEP) 

is jointly sponsored by the National Institutes of Health (NIH) and the Centers for Disease Control 

and Prevention (CDC) with the support of more than 200 partner organizations. 

National Diabetes Education Program
 

1-888-693-NDEP (6337) TTY: 1-866-569-1162 www.YourDiabetesInfo.org
 

NDEP-125