Enrollment Materials and Referral Tracking Form

ENROLLMENT MATERIALS & REFERRAL TRACKING FORM

OVERVIEW

The Enrollment Materials and Referral Tracking Form was developed to help track activities focused on increasing enrollment and participation in lifestyle change programs (LCP) such as the National Diabetes Prevention Program (National DPP). This form should be completed by a lifestyle change coach and/or program staff at your organization. Overall instructions are provided below and more detailed guidance is provided on the next page. This form should take no more than 15 minutes to complete.

INSTRUCTIONS
How to Use:	Before you begin, please make sure you have included your initials, your role and your organization’s name in the blue box at the top of the next page. If you are using a hard copy of this tool and need additional space, please write your answers on a blank page and attach it to this form.
To Be Completed By:	The Enrollment Materials & Referral Tracking Form should be completed by a lifestyle change coach or a program staff member who is familiar with the enrollment efforts at your organization.
When to Use:	Please update this tracking form regularly as your organization implements enrollment activities.
When to Submit:	The lifestyle coach or program staff member should send/submit the form to the Abt Evaluation Team as soon as the enrollment period has ended and the LCP has begun. Send to: Tara Earl, 2200 Century Center Parkway Suite 950 Atlanta, GA 30320 Or Email: Tara_Earl@abtassoc.com
Who to Contact with Questions:	Please contact Tara Earl, Program Manager, at (404) 946-6308 if you have any questions about how to complete the form.

Your Initials:
Start Date of Enrollment Activities:
Your Role:
Organization’s Name:
Anticipated LCP Start Date:

ENROLLMENT ACTIVITIES

In the table below, please indicate the number of materials disseminated by type. If the type of material is not listed, you can write it in next to “Other.” In the notes column, please indicate where each type of enrollment material was disseminated (as applicable) and to who (e.g., currently enrolled LCP participants, healthcare providers, churches, etc). For each enrollment material reported below, please set aside a copy that can be shared with the CDC team. Last, please also answer questions 2-5 below the table.

DISSEMINATION OF MATERIALS
How many enrollment materials were disseminated to organizations/individuals to promote participation in the LCP?
Type	Quantity	Notes
Brochures
Post-It Notes
Fact Sheets
Checklists
Other: ________________________
Other: ________________________
Other: ________________________
Other: ________________________

2. How many healthcare organizations/settings were sent/received enrollment materials? _____________

3. How many healthcare providers (e.g., physicians, nurse practitioners, physician assistants, or nurses) in total did you give materials to for use with their patients (if known)? _____________

4. How many LCP participants were trained to invite potentially eligible friends and family to an Information Session? _____________

5. In total, how many referrals to Information Sessions were made by current or past LCP participants? _______________

6. Did the lifestyle change coach or program staff follow-up with attendees after the Information Session to support their attendance at the first session of the LCP? (circle answer)

   1. Yes

   2. No

   3. Not sure

.