Program Name
Program Information Cover Sheet
Instructions to Program Facilitator(s): Please provide the requested details about this program. Please print clearly. Use this as a cover sheet for the completed data collection forms to return to the Survey Coordinator.
Site Name:
Address:
City: State: Zip:
2. Program Facilitator Names (please provide full first and last names and provide the daytime phone number and/or email of the best person to contact about any questions on the forms)
First Name
First Name
Last Name
Last Name
Ph: (___) _____ - ____________
Email:
Would you like to receive program information from the National CDSME Resource Center? Yes No
Ph: (___) _____ - ____________
Email:
Would you like to receive program information from National CDSME Resource Center? Yes No
3. Program Start Date (mm/dd/yyyy): / /
End Date (mm/dd/yyyy): / / __
4. Did you offer a “Session 0” with this program? (Session 0 is an optional pre-program session. Not all programs offer a Session 0.)
Yes
No
Don’t know
5. What type of program is this? Mark only one. [Note to grantee: adapt this section to fit
local programming]
Active Living Every Day
Arthritis Foundation Aquatic Program
Arthritis Foundation Exercise Program
BRI Care Consultation
Cancer: Thriving and Surviving
Chronic Disease Self-Management Program (CDSMP)
Chronic Pain Self-Management Program (CPSMP)
Diabetes Self-Management Program (DSMP)
Eat Smart, Move More, Weigh Less
EnhanceFitness
EnhanceWellness
Fit and Strong!
Geri-Fit
Health Coaches for Hypertension Control
Healthy IDEAS
Healthy Moves for Aging Well
HomeMeds
Living Well in the Community
On the Move
PEARLS
Positive Self-Management Program for HIV
Programa de Manejo Personal de la Diabetes (Spanish DSMP)
Screening, Brief Intervention, and Referral to Treatment (SBIRT)
Tomando Control de su Salud (Spanish CDSMP)
Walk With Ease
Wellness Recovery Action Plan (WRAP)
Workplace Chronic Disease Self-Management Program (wCDSMP)
Please check which language you used when offering this program:
English
Spanish
Other: ________________________________________
What funding source(s) were used to support this program? Check all that apply.
ACL CDSME Grant
Older Americans Act (Title III-D, Title III-E, etc.)
Centers for Disease Control and Prevention
Other Federal Funding
Medicaid/Medicaid Waiver
Medicare/Medicare Advantage
Other Health Care Payer
Foundation Funding
Corporate Sponsor
Don’t Know
Other: ________________________________________
Paperwork Reduction Act Public Burden Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless such collection displays a valid OMB control number (OMB 0985-0036). Public reporting burden for this collection of information is estimated to average .33 hours per response, including time for gathering and maintaining the data needed and completing and reviewing the collection of information. The obligation to respond to this collection is required to retain or maintain benefits under the statutory authority of Public Law 115-245.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Workshop Information Cover Sheet |
Author | U.S. Administration on Aging |
File Modified | 0000-00-00 |
File Created | 2021-01-15 |