Dow: Prevent T2 Pre-Assessment and Registration (2026)

PreventT2 Registration

Starts May 26 I Microsoft Teams Sessions | 12:00-12:45 pm CT/1:00-1:45 pm ET
Are you covered by a Dow health insurance plan? Please note that if you are not covered you are unable to participate in this program.
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Email
example@example.com
Preferred Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Are you an employee, spouse, or dependent?
What is the employee's primary work location?

Other
Pre-Assessment

Please take a few minutes of your time to answer the questions below. These initial demographic questions are needed for program admission. They will be asked at the both the beginning and the end of the program to help us better understand the behavior change that occurs during the program. Please rest assured that all information you provide is confidential and will not be shared with your employer.

The first question on the pre-assessment requires you to take a pre-test created by the Centers for Disease Control and the American Diabetes Association. Here is the link to the pretest. Complete it and then enter your result in the box below.
Enter your result from the CDC pretest.
Score should be >5.
What is your ethnicity?
What is your highest level of education completed?
What is your gender?
What is your state of residence?

Street Address

Street Address Line 2

CityState

Zip Code
What is your height? (in inches)
ex. 64"
What is your starting weight? (in pounds)
ex. 178
How much time in the past seven days have you spent exercising? (in minutes)
ex. 30 + 40 + 15 + 25 = 110
How confident are you that you can lose weight?

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
How important is your health to you right now?

1

2

3

4

5

6

7

8

9

10

1 is Low, 10 is High
Which statement below best describes your current physical activity level?

Please state how much you agree or disagree with the following statements:

Rows	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I am confident I can exercise if there is bad weather, when I'm tired or I feel I don't have time.
There are a variety of exercise activities I enjoy.
I feel a good amount of energy most days.
I sleep well most nights.

On average, how many hours of sleep do you get each night?

5

6

7

8

9

5 is or less, 9 is or more
Which statement below best describes your current diet?

Please state how much you agree or disagree with the following statements:

Rows	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I am confident I can make my diet healthier.
I am confident I can make healthy meals in the kitchen.
Before I choose what to eat I consider if it is healthy

Rows	Never	Occasionally	Sometimes	Frequently	Always
How often do you drink soft drinks or other carbonated beverages?
In the last 2 weeks, how often did you buy food from a restaurant?
In the last 2 weeks, how often did your eat "instant" or "packaged" foods?

What inspired you to enroll in the program?

Other
In the past year have you had:
Do you have a history of gestational diabetes? (Diabetes during pregnancy)
Should be Empty:

PreventT2 Registration