California Diabetes and Pregnancy Program
Sweet Success

Annual Affiliate Survey
Due January 31, 2020

Part 1 (of 3): Affiliate General Information

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* 1. Please list the Primary CDAPP Sweet Success Affiliate site name that you are completing this Annual Affiliate Survey for.

	Affiliate Name
Primary CDAPP Sweet Success Affiliate Name:	Primary CDAPP Sweet Success Affiliate Name: Affiliate Name menu

If your primary affiliate site is not listed above or it is incorrectly displayed, please select Not Listed at the bottom and type the full name below:

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* 2. Have you been a CDAPP Sweet Success Affiliate in the past?

Yes

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* 3. Are you completing the survey for more than one (1) site?

Yes

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* 4. Affiliate Medical Director Name:

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* 5. My CDAPP Sweet Success site most identifies as being a part of a:

Freestanding Clinic/Private Medical Office

University System

County Hospital

Healthcare System (ex. Sutter, Dignity, Sharp)

Private Hospital

Other (please specify)

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* 6. Affiliate Address:

Street Adress + Suite, Building, or Room Number

City

Zip Code

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* 7. Please view your Affiliate Site(s) on our Affiliate Locator Online and tell us if you would like anything altered or added (i.e. phone number, website added, address change). Answer only the fields that apply.

Change my Affiliate or Satellite Name to:

Change my Phone Number to:

Change my Affiliate Address to:

Add an Email:

Add a Website:

Other (please type additional comments):